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PubMed1994

Long-term results of venous valve reconstruction: a four- to twenty-one-year follow-up.

PURPOSE: The purpose of this study is to describe the very long-term clinical, hemodynamic, and imaging results of venous valve reconstruction for reflux disease in patients with chronic venous insufficiency. METHODS: There were 51 extremities (48 patients) with follow-up of 4 to 21 years with a mean of 10.6 years. Clinical severity was graded as asymptomatic (class 0), mildly symptomatic (class 1), moderately symptomatic but without ulceration (class 2), or severely symptomatic with or without ulceration (class 3). Preoperative and postoperative evaluation consisted of history and physical examination, ascending venography (preoperative only), ambulatory venous pressures or photoplethysmography, and descending venography or duplex scanning. RESULTS: Before surgery, 49 (96%) of 51 limbs demonstrated severe, class 3 disease, and two limbs were classified as class 2 disease. After venous valve reconstruction by either direct femoral vein valve repair, transposition, or transplantation, long-term clinical success of achieving a class 0 or 1 result (by life-table analysis) was 60% at 10 years. Thirty-three percent demonstrated a class 0 result in which the limbs were free from symptoms and had no need for long-term elastic support. After 6 years clinical results were stable and did not deteriorate. Incompetent perforators were identified in 31 cases and were treated selectively. Three disease patterns of chronic venous insufficiency were identified: primary valve insufficiency 43%, postthrombotic syndrome 31%, and a group consisting of both primary valve insufficiency of the superficial femoral vein and postthrombotic syndrome of the calf veins (primary valve insufficiency-postthrombotic syndrome) 26%. Ten-year cumulative clinical success was clearly superior in limbs with primary valve insufficiency corrected by valve repair (73%) as opposed to those with postthrombotic syndrome treated by either valve transposition or transplantation (43%) (p = 0.029). Clinical outcome correlated strongly with postoperative imaging results, and durability of valve repair was confirmed by demonstrating competence up to 16 years after the operation. Significant improvement in ambulatory venous pressure (mean percentage of pressure fall and refill time) was found in limbs with class 0 or 1 outcome; however, values did not reach "normal" levels in all cases. Recurrent ulcerations after the operation were attributed to failed reconstructions (10), incompetent profunda femoris veins (three), incompetent perforators (three), and concomitant lymphedema (one). CONCLUSIONS: This report highlights a difference found in very long-term prognosis of surgical treatment of primary valve insufficiency as opposed to postthrombotic syndrome. Long-term elimination of symptoms of chronic venous insufficiency is achieved by valve repair for primary valve insufficiency beyond 10 years, whereas late results of treatment of postthrombotic syndrome in this study was accompanied by high recurrence rates and warrants further investigation.

Axillary Vein↗

PubMed1989

Clinical and noninvasive assessment of venous disease as related to pulmonary embolism.

Proper management of patients with venous disease requires recognition of the various syndromes and an accurate objective diagnosis. Unfortunately many physicians are unfamiliar with the different venous disorders and are unaware of the fallibility of the clinical diagnosis of these syndromes. This article reviews the six common venous conditions that collectively are more common than coronary or peripheral arterial disease. Acute and recurrent deep vein thrombosis, postthrombotic syndrome, superficial thrombophlebitis, varicose veins, and pulmonary embolism may all confront the physician regardless of his or her specialty. Clinical recognition and differentiation of these disorders along with appropriate use of objective, noninvasive isotopic and venographic studies should lead to accurate diagnosis and management of these venous syndromes. Such an approach will permit prompt and appropriate therapy for disabling and potentially life-threatening venous thromboembolism while avoiding unnecessary anticoagulation of patients with disorders mimicking venous disease.

Acute Disease↗

PubMed1994

[Subclavian vein thrombosis: medical treatment].

Thromboses of the subclavian vein are rare. However there is a higher incidence due to the increasing use of central venous catheters and pacemakers. Thoracic outlet syndrome is no longer the main cause. Thromboses may be clinically apparent, however when they are caused by the insertion of a catheter, thromboses may be symptom-free. Phlebography is the gold standard for the diagnosis. B mode ultra-sounds may give false results in that particular location. The optimum treatment of subclavian thromboses should prevent the occurrence of pulmonary embolisms, and the development of post-thrombotic syndrome. Heparin followed by anti-vitamin K meets these two objectives in the majority of cases. The risks of thrombolytic therapy is, in our opinion, unacceptable to promote thrombolysis to treat upper limb venous thrombosis. Surgery is indicated in cases of phlematia caerulea which are extremely rare, and in cases of septic thrombosis. The preventive treatment of the opposite side of a symptomatic thoracic outlet syndrome, is questionable, except in the case where the findings of the clinical examination, B mode ultrasound and phlebography results, are in favor of a intermittent compression of the vein with a risk of thrombosis.

Arm↗

PubMed1989

[Relation between post-thrombotic syndrome, ADP-induced thrombocyte aggregation and intrathrombocyte calcium content].

Correlation between postthrombotic syndrome, ADP-induced aggregation and intracellular calcium concentration. This study presents a comparison of the ADP-induced platelet aggregation and free cytosolic platelet calcium concentration between patients with postthrombotic syndrome and healthy volunteers. The half maximal effective dose of the platelet aggregation induced by ADP was significantly decreased in postthrombotic syndrome (p less than 0.005). The mean values were 0.42 mumol/l in postthrombotic syndrome (n = 22) and 1.00 mumol/l in normal controls (n = 25). The free intracellular calcium concentration was slightly but significantly diminished in patients compared with healthy volunteers. In both groups there was seen a remarkable interindividual spread of platelet calcium concentrations. There was seen no significant correlation between cytosolic calcium concentration of platelets and the half maximal effective dose of ADP-induction. Therefore the considerable enhanced aggregability in postthrombotic syndrome cannot explained with altered cytosolic calcium content of platelets.

Adenosine Diphosphate↗

PubMed1998

Long-term consequences of deep vein thrombosis.

Following an overt episode of deep vein thrombosis (DVT), the long-term prognosis of the patient is predominantly obscured by three natural complications: recurrence of venous thromboembolism (VTE), post-thrombotic syndrome and death. Antithrombotic treatments have been proven effective in preventing recurrence of VTE but carry the risk of major bleeding. A high mortality rate persists during the first year following an acute VTE, with a small but continuing risk beyond the first year. Recurrences of VTE account for the minority of causes of deaths. With effective initial anticoagulant treatment, the early (within approximately 3 months) risk of recurrence is 3-6%. Long-term follow-up studies have shown that although the risk of recurrence of VTE beyond the first 6 months is lower, the risk persists over several years. Approximately 25% of DVT patients remain asymptomatic in the long term but severe signs of post-thrombotic syndrome (ulceration) are observed in 2-10% of patients 10 years after DVT. Major advances have been made in the management of acute VTE but the excess risks of death, recurrence of VTE and post-thrombotic syndrome persist for several years following the initial event. Appropriate therapeutic strategies for these events are still being developed and future study should be directed towards finding the optimal regimen for patients who require prolonged treatment.

Anticoagulants↗

PubMed2004

Division of incompetent perforator veins and subfascial interposition of a polypropylene foil in post-thrombotic syndrome. Preliminary results.

AIM: The safety, feasibility and early efficacy of subfascial endoscopic perforator surgery was gradually accepted for patients who had severe chronic venous insufficiency but, in the literature, the recurrence rate of ulceration is about 10-40%, especially in patients with previous deep vein thrombosis (DVT). METHODS: From October 1998 to February 2002, 205 patients with 280 inferior leg ulcers were followed; 115 had venous ulcers but only 20 patients had chronic ulcers with previous DVT; 4 patients were excluded and only 16 patients (9 female, 7 male, mean age 61 years) with 18 chronic ulcers were included. These patients underwent sub-aponeurotic interruption of perforating veins with blind technique in association with subfascial interposition of a hand-made polypropylene foil. Eight of these patients had persistent non-healing ulcers at the time of surgery and 10 had chronic recurrent ulceration healed at the time of the surgical procedure. All patients were assessed clinically and with duplex scanning. RESULTS: The follow-up was done clinically and with eco-Doppler from 6 to 38 months with a mean follow up period of 23.2 months. The healing rate was 100%. The 2-year life table incidence of ulcer recurrence was 0%. Hospital stay ranged from 1-2 days, early operative complications included extensive ecchymosis in 1 patient, oedema in 3 patients. CONCLUSION: The division of perforating veins, with the subfascial support of a polypropylene foil give promising results in the treatment of venous ulcers in post-thrombotic syndrome with low morbidity and short hospital stay.

Angioscopy↗

PubMed1999

Intermittent compression units for severe post-phlebitic syndrome: a randomized crossover study.

BACKGROUND: Although uncommon, severe post-phlebitic syndrome may be associated with persistent, intractable pain and swelling that interfere with work and leisure activities. This study was performed to determine whether intermittent compression therapy with an extremity pump benefits patients with this condition and, if so, whether the benefit is sustained. METHODS: The study was a randomized crossover trial. Over the period 1990 to 1996, all patients in the clinical thromboembolism program of an Ontario teaching hospital who had a history of deep vein thrombosis and intractable symptoms of post-phlebitic syndrome were recruited into the study. The study involved using an extremity pump twice daily for a total of 2 months (20 minutes per session). The patients were randomly assigned to use either a therapeutic pressure (50 mm Hg) or a placebo pressure (15 mm Hg) for the first month. For the second month, the patients used the other pressure. A questionnaire assessing symptoms and functional status served as the primary outcome measure and was administered at the end of each 1-month period. A symptom score was derived by summing the scores for individual questions. At the end of the 2-month study, patients were asked to indicate their treatment preference and to rate the importance of the difference between the 12 pressures. Treatment was considered successful if the patient preferred the therapeutic pressure and stated that he or she would continue using the extremity pump and that the difference between the therapeutic and placebo pressures was of at least slight importance. All other combinations of responses were considered to represent treatment failure. Patients whose treatment was classified as successful were offered the opportunity to keep the pump and to alter pressure, frequency and duration of pump use to optimize symptom management. In July 1996 the authors contacted all study participants whose treatment had been classified as successful to determine whether they were still using the pump and, if so, whether they were still deriving benefit. RESULTS: In total 15 consecutive patients (12 women and 3 men) were enrolled in the study. The symptom scores were significantly better with the therapeutic pressure (mean 16.5) than with the placebo pressure (mean 14.4) (paired t-test, p = 0.007). The treatment for 12 of the patients (80%, 95% confidence interval 52% to 96%) was considered successful. Of these, 9 patients continued to use the pump beyond the crossover study and to derive benefit. INTERPRETATION: The authors conclude that a trial of pump therapy is worthwhile for patients with severe post-phlebitic syndrome and that a sustained beneficial response can be expected in most such patients.

Adult↗

PubMed1989

Anticardiolipin syndrome in plastic surgery of the breast.

A 38-year-old female patient had bilateral silicone-made prosthesis implantation performed 17 years ago. Three years after surgery, she had a series of spontaneous miscarriages, later she developed recurrent venous and arterial thromboses. Laboratory tests detected antibodies against cardiolipin and the diagnosis of cardiolipin syndrome was established. The authors discuss the possible association between surgery and the patient's current disease.

Abortion, Habitual↗

PubMed1997

[Characterization of post-thrombotic reflux with color-coded duplex ultrasound diagnosis].

Reflux in deep veins is accepted as the most important pathophysiologic phenomenon in postthrombotic syndrome. The data proved by colour coded duplex sonography are demonstrated in this summary. As the different methods to provoke reflux yet are not examined we present our own results. A velocity of more than 10 cm/sec. at the time of the greatest reflux, a duration of reflux of more than 2 seconds and the lack of the valve signal are the best criteria to detect and quantify a postthrombotic syndromE by colour coded duplex sonography. Using Valsalva's maneuver, calf compression and cuff compression test to provoke reflux, the cuff compression technique proved to be the best one.

Adult↗

PubMed2000

[Changes in microcirculation and their correction in patients with varicose veins and post-thrombotic syndrome].

Variety of disturbances of microcirculation can be stipulated by vasomotorial disfunction's of blood circulation in terminal vascular bed, changes of rheologic and coagulative characteristics of blood as well as morphological changes of structure of tissue and vessels of microcirculatory bed of destructed lower limb. In case of a varicose disease without complications changes of microvessels are considered to be compensatory adaptation. Patients suffering from a complicated type of varicose disease and post-thrombotic syndrome have "failure" of compensatory adaptation reaction. It results from significant functional disturbances of microcirculation and sudden morphological changes of structure of blood and lymphatic capillaries and tissue of a destructed lower limb. Correlative dependence can be found between degree of clinical evidences and a level of structural changes of microcirculatory bed. They are mostly significant in groups of patients having complicated varicose disease and post-thrombotic syndrome. It was shown that functional and morphological states of microcirculatory bed are of prognostic importance for estimation of effectiveness of operative interferences during diseases being analysed.

Adolescent↗

PubMedDate not supplied

Thrombectomy for acute deep vein thrombosis: prevention of postthrombotic syndrome.

Ninety-six limbs of 89 patients with acute deep vein thrombosis of the lower extremity were followed for 1 to 18 years. In the thrombectomy group (43 limbs), the cumulative incidence of pigmentation at the 15th year was 15%, but no stasis ulcers occurred throughout the follow-up period. In the conservative treatment group (53 limbs), the cumulative incidence of pigmentation at the 15th year was 41%, and that of stasis ulceration was 27%. Fogarty thrombectomy restricted below the pelvic vein spur and removal of thrombi in the leg veins by manual milking is sufficient to relieve early morbidity, preserve venous valve function, and promote intrapelvic collateral circulation. Preservation of venous valves in the femoropopliteal region is a key to the prevention of postthrombotic syndrome. Thrombectomy within 5 days of the onset of symptoms is recommended for patients with iliofemoropopliteal venous thrombosis.

Adult↗

PubMed1997

On the relationship between changes in the deep veins evaluated by duplex sonography and the postthrombotic syndrome 12 years after deep vein thrombosis.

In a prospective study we performed color duplex ultrasonography to evaluate patency and valvular function of previous thrombosed veins 12 years after the acute thrombosis. Normal clinical findings were found in 64% of the patients, mild postthrombotic skin changes in 28%, and marked trophic changes in 5%; only 1 venous ulcer occurred. In 39 patients, 114 initially thrombosed vein segments were evaluated. Thirty-seven of 72 proximal segments were completely recanalized (23 with valvular incompetence) and 21 segments exhibited partial recanalization (19 with valvular incompetence). Superficial femoral vein segments were completely occluded in 19%, however, excellent collateralization was provided via the deep femoral vein. Thromboses of the posterior tibial vein demonstrated a high rate of recanalization with development of valvular incompetence in 52%. Whereas obstruction and valvular incompetence as single factors led to a postthrombotic leg in 8.5% and 33%, respectively, the most frequent cause for the development of the postthrombotic syndrome was the combination of reflux plus obstruction in the deep veins (50%). Compression therapy with elastic compression stockings is recommended for at least 5 years after the acute thrombosis.

Adult↗

PubMed1997

Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.

BACKGROUND: Post-thrombotic syndrome varies from mild oedema to incapacitating swelling with pain and ulceration. We investigated the rate of post-thrombotic syndrome after a first episode of deep-vein thrombosis and assessed the preventive effect of direct application of a sized-to-fit graded compression stocking. METHODS: Patients with a first episode of venogram-proven proximal deep-vein thrombosis were randomly assigned no stockings (the control group) or made-to-measure graded compression elastic stockings for at least 2 years. Post-thrombotic syndrome was assessed with a standard scoring system that combined clinical characteristics and objective leg measurements. Patients were assessed every 3 months during the first 2 years, and every 6 months thereafter for at least 5 years. The cumulative incidence of mild-to-moderate post-thrombotic syndrome was the primary outcome measure. FINDINGS: Of the 315 consecutive outpatients considered for inclusion, 44 were excluded and 77 did not consent to take part. 194 patients were randomly assigned compression stockings (n = 96) or no stockings (n = 98). The median follow-up was 76 months (range 60-96) in both groups. Mild-to-moderate post-thrombotic syndrome (score > or = 3 plus one clinical sign) occurred in 19 (20%) patients in the stocking group and in 46 (47%) control-group patients (p < 0.001). 11 (11%) patients in the stocking group developed severe post-thrombotic syndrome (score > or = 4), compared with 23 (23%) patients in the control group (p < 0.001). In both groups, most cases of post-thrombotic syndrome occurred within 24 months of the acute thrombotic event. INTERPRETATION: About 60% of patients with a first episode of proximal deep-vein thrombosis develop post-thrombotic syndrome within 2 years. A sized-to-fit compression stocking reduced this rate by about 50%.

Bandages↗

PubMed1991

[Doppler ultrasound study in patients with post-thrombotic syndrome: a screening method].

Doppler ultrasound has been a useful, noninvasive technique in the diagnosis of deep venous thrombosis. Until now, primary or secondary varicosities could only be clarified through phlebography or strain-gauge plethysmography. The aim of our study was to assess the flow time in 28 patients with primary varicose veins and postthrombotic syndrome using Doppler ultrasound. The Wilcoxon-Test was used for statistical reviewing in the second test, revealing a significant difference between both groups. The confidence intervals did not overlap.

Adult↗

PubMed1991

[Practical proposals for overcoming problems with phlebography].

Venography is considered the gold standard in the diagnosis of venous disease. In the everyday practice, however, it is not used according to this attribute. The article scrutinizes the reasons for the discrepancy, emphasizes the possibilities wrongly renounced to and gives advice to a better indication for and execution of venography. Arguments not to use venography regularly to diagnose or exclude deep venous thrombosis, include claims that it would be superfluous, not readily available, invasive and expensive. Such considerations do not take into account that the clinical diagnosis it not better than tossing a coin. Real difficulties may occur in the evaluation of complicated superficial disease and the postthrombotic syndrome. The problems are minimized by using a methodology based on pathophysiologic knowledge and strictly aimed to solve specific therapeutic questions. The article stresses the need for a proper prevenographic work-up and for a technique tailored to the clinical situation of each individual patient.

Humans↗

PubMed1990

[Dynamic measuring of blood pressure in the gastrocnemius muscle for evaluation of the status of venous hemodynamics in the lower extremity].

The work presents results of measuring the intramuscular pressure in musculus gastrocnemius in healthy people and patients with a pathology of major venous vessels of lower extremities (varicose dilatation of the veins, ++post-thrombophlebitic syndrome with recanalization of profound veins, acute iliofemoral venous thrombosis). It was found that the intramuscular pressure indices correlate with indications of phlebotonometry and may be used for the assessment of the state of venous hemodynamics in lower extremities.

Femoral Vein↗

PubMed2006

Hemodynamic and morphologic evaluation of sequelae of primary upper extremity deep venous thromboses treated with anticoagulation.

OBJECTIVES: This study was performed to describe venous function, residual morphologic abnormalities, and the occurrence of post-thrombotic syndrome in patients with conservatively treated primary upper-extremity deep venous thromboses (UEDVT). METHOD: This was a retrospective follow-up study of 31 patients with previous primary UEDVT treated with anticoagulation only, identified by a search of medical records. The mean follow-up time was 5 years. The patients were evaluated by interview, clinical examination, computerized strain-gauge plethysmography, and color duplex ultrasound imaging. The grade of post-thrombotic syndrome was rated according to the Villalta score (0 to 3 on each of four subjective and five clinically assessed features). RESULTS: The rate of venous emptying was significantly lower in the arms with DVTs than in the contralateral arms (P < .001). Eleven of the patients (35%) had a remaining outflow obstruction in the affected arm (venous emptying <68 mL/100 mL per min). Eighteen (58%) had a residual thrombus according to color duplex ultrasound scans, with four remaining occluded subclavian veins. None of the patients had deep or superficial venous reflux. There was no statistically significant relationship between plethysmographic and duplex findings. Most (77%) of the patients reported remaining symptoms in the affected arm, and there was a significant side difference in upper arm circumference (P < .001). Approximately one third had developed a moderate grade of post-thrombotic syndrome according to the Villalta score (total, 5 to 9). No significant relation was evident between the post-thrombotic syndrome score and duplex findings. Patients with post-thrombotic syndrome had a lower venous emptying value than those without (69 vs 84 mL/100 mL per min), but this difference was not statistically significant. CONCLUSIONS: Patients with conservatively treated previous primary UEDVT had significantly reduced venous outflow capacity and a residual thrombus was common. Swelling of the arm was the most common symptom, and one third had a moderate grade of post-thrombotic syndrome. However, there was no clear relation between hemodynamic and morphologic factors and the development of post-thrombotic syndrome in these 31 patients, examined at a mean of 5 years after an acute DVT episode.

Adult↗

PubMed1994

[Formation of subfascial lymphovenous anastomoses on the foot].

The author suggests a new modification of operation for formation of subfascial lymphovenous anastomoses (LVA) on the dorsum of the foot in treatment of edema of the lower limbs. Sixty-two patients underwent operation. In 34 patients of the control group an epifascial LVA was formed on the dorsal surface of the foot. The operation for LVA anastomosis was combined with fenestration of the leg fascia. A positive effect of various degree was produced in the postthrombotic syndrome in 84% of the studied patients (in 29% of the controls) and in 94% of cases of II degree lymphedema (in 56% of the controls). The expediency of subfascial LVA is substantiated clinically and physiologically.

Adult↗