Validation of a new duplex derived haemodynamic effectiveness score, the saphenous treatment score, in quantifying varicose vein treatments

ObjectivesTo evaluate a duplex-derived score for varicose vein treatments using numerical values of haemodynamic effectiveness.DesignThe saphenous treatment score (STS) was developed prospectively to compare the effect of endovenous treatments on reflux within saphenous segments.PatientsSixty-six patients were randomised to endovenous laser ablation (EVLA) or ultrasound-guided foam sclerotherapy (UGFS) to the great saphenous vein (GSV).MethodsAssessments included the Aberdeen varicose vein severity score (AVVSS), the venous clinical severity score (VCSS), the venous filling index (VFI) and the STS.ResultsA mean STS of 5.70 decreased to 3.30, P < .0005, post-treatment. The median (IQR) AVVSS, VCSS and VFI (ml/sec) decreased from 21.52(15.48) to 18.86(11.27), P = .14, from 6(4) to 3(4), P < .0005 and from 7.1(6.9) to 1.9(.9) P < .0005, respectively. In 15 patients requiring additional UGFS the mean STS values decreased from 5.8 to 4.13 and then to 2.6 P < .0005, respectively. The individual above and below knee mean treatment differences in STS on 38 EVLA and 28 UGFS patients were 1.92 and .87 (EVLA) compared to 1.57and .29 (UGFS) P = .001, respectively.ConclusionsThe STS has been shown to grade the haemodynamic effects of different treatments as well as ongoing treatments on the GSV.     

Photoplethysmographic Venous Refilling Times Following Ultrasound Guided Foam Sclerotherapy for Symptomatic Superficial Venous Reflux: Relationship with Clinical Outcomes

IntroductionDigital photoplethysmography (PPG) provides an inexpensive, reproducible, quantitative, non-invasive assessment of lower limb venous function.AimTo examine the relationship between venous refilling time (VRT) and severity of venous disease, and also between changes in VRT and symptomatic improvement after ultrasound guided foam sclerotherapy (UGFS) for symptomatic superficial venous reflux (SVR).MethodsPrior to and 6 months after UGFS, 246 patients (317 limbs) completed a symptom questionnaire, underwent duplex ultrasonography and clinical assessment, and VRT measurement by digital PPG. Health related quality of life (HRQL) questionnaires were also completed.ResultsMedian VRT improved from 11 to 31 s (P < 0.0005, Wilcoxon Signed Ranks). Abnormal VRT (<20 s) correlated well with the presence of SVR on duplex (sensitivity 75%, specificity 94%). Pre-treatment there was a significant relationship between reducing VRT and increasing CEAP clinical grade (P < 0.0005, χ²), extent of SVR on duplex (P < 0.0005) and a non-significant relationship with overall increasing symptom severity (P = 0.097). Relief of all symptoms was more likely when there was normalisation of VRT after treatment (80% vs. 65%, P < 0.0005, χ²). Pre-treatment VRT correlated with both generic physical (r = 0.428, P = 0.002) and disease-specific (r = ?0.413, P = 0.003, Spearman's rank) HRQL.ConclusionsUGFS for SVR improves VRT measured by digital PPG and that improvement correlates with symptom relief.     

Blocking the Saphenofemoral Junction During Ultrasound-Guided Foam Sclerotherapy – Assessment of a Presumed Safety-measure Procedure

ObjectivesUltrasound-guided foam sclerotherapy (UGFS) is a technique in which a mixture of sclerosing drug and gas is used to treat varicose veins. Several authors have demonstrated transient systemic effects after UGFS. These effects are not well understood but probably originate from a systemic distribution of the sclerosing foam. Therefore, safety measures have been developed to prevent foam from flowing into the deep venous system. The aim of the study is to evaluate whether blockage of the saphenofemoral (SF) junction by either manual compression or surgical ligation prevents microbubbles from leaking into the deep venous circulation.MethodsTo detect the distribution of microbubbles, radioactive pertechnetate (^99mTcO₄^?) was added to the foam solution. Initially, in vitro trials were performed in the laboratory to investigate the effect of ^99mTc on foam stability. The time taken for foam to liquefy was measured for foam alone and for the mixture with ^99mTc. In subsequent research, eight varicose great saphenous veins (GSVs) were treated by UGFS. In three patients, this treatment was preceded by surgical ligation of the SF junction. In three patients, the groin was manually compressed during UGFS. In two patients, UGFS was performed without compression of the groin.ResultsIn vitro, ^99mTc did not influence foam stability; after 2.6 min all foam had reduced to liquid, regardless of whether ^99mTc had been added or not. In vivo trials showed that all patients showed a decrease in the cumulative amount of ^99mTc detected in the GSV following polidocanol-^99mTc mixture injection. However, the decrease of radioactivity was slightly reduced when compression or ligation of the SF junction was performed.ConclusionsBlocking the SF junction during UGFS using either manual compression or ligation does not prevent, but may reduce the flow of foam into the femoral vein.     

Popliteal Vein Compression Under General Anaesthesia

ObjectivesTo determine the incidence of popliteal vein compression in supine patients, who are under general anaesthesia and using heel elevators.DesignA prospective cohort study.MethodsThe popliteal veins of 50 patients, lying supine under general anaesthesia, were insonated using duplex ultrasonography to determine the incidence of popliteal vein compression when the knees were flexed and extended.ResultThere was a statistically significant reduction in popliteal vein diameter in extension compared with the diameter in flexion (median diameter: flexed 7.6 mm, extended 2.1 mm, p < 0.001, Wilcoxon test). In extension, 43% of veins occluded, and a further 21% was compressed by ≥50%. There was a significant relationship to body mass index (BMI) but not to height, gender or age; all patients with BMI ≥30 displayed narrowing at least one vein by ≥50%. The relative risk of vein narrowing ≥50% or occlusion was 1.55 for BMI ≥25 versus <25, and 1.67 for BMI ≥30 versus <25.ConclusionKnee hyperextension in supine patients during general anaesthesia leads to popliteal vein compression or occlusion. The likelihood of compression increases with higher BMIs.     

Prospective randomised comparative study of visual foam sclerotherapy alone or in combination with ultrasound-guided foam sclerotherapy for treatment of superficial venous insufficiency: preliminary report

ObjectiveThe aim of the study is to compare ultrasound-guided foam sclerotherapy (UGFS: injection of foam sclerosant under ultrasound guidance) of the great saphenous vein (GSV) combined with visual foam sclerotherapy (VFS: injection of foam sclerosant under visual control) for varicose tributary veins and VFS alone in the treatment of GSV reflux.Design and methodsA total of 133 limbs in 97 patients with GSV reflux were randomised to receive either VFS alone or VFS combined with UGFS. In both groups, 1% polidocanol foam was used. Assessments included duplex ultrasonography, evaluation of Venous Clinical Severity Scores (VCSS) and CEAP (clinical, etiologic, anatomic, and pathophysiologic) scores. Ultrasonographic inspection of the foam in the GSV was carried out during 5 min before compression was applied. The primary ‘end’ point of the study was obliteration of the GSV at 6 months.ResultsA total of 51 limbs in 48 patients were treated with UGFS + VFS and the remaining 52 limbs in 49 patients were treated with VFS alone. There were no significant inter-group differences in patient age, male: female ratio, height, weight, body mass index, CEAP clinical scores or VCSS. The GSV diameter was 6.0 ± 1.7 mm (median ± interquartile range) in the UGFS + VFS group and 5.7 ± 1.6 mm in the VFS group (p = 0.419). The mean injected volume of foam for varicose tributary veins was 4 ± 2 ml in the UGFS + VFS group and 6 ± 2 ml in the VFS group, a significantly higher amount of foam being used in the latter (p < 0.001). However, the mean total amount of foam was greater in limbs treated with UFGS + VFS than in those treated with VFS alone (p = 0.017). Ultrasonographic inspection revealed complete vasospasm of the GSV in 37 (72.5%) limbs in the UGFS + VFS group and 29 (55.8%) in the VFS group during sclerotherapy (p = 0.097). At 6-month follow-up, complete occlusion was found in 23 limbs (45.1%) treated with UGFS + VFS and in 22 limbs (42.3%) treated with VFS. The difference between the two groups was not significant (p = 0.775). Reflux was absent in 30 limbs (58.8%) treated with UGFS + VFS and in 37 (71.2%) treated with VFS (p = 0.190). There was no inter-group difference in post-treatment VCSS (p = 0.223).ConclusionsThese results show that UGFS + VFS and VFS are equally effective for the treatment of GSV reflux, despite the lower volume of foam used for VFS alone.     

Ultrasound-guided foam sclerotherapy as a therapeutic modality in venous ulceration

ObjectivesThe objective of this systematic review and meta-analysis was to evaluate rates of ulcer healing following ultrasound-guided foam sclerotherapy (UGFS).MethodsThe MEDLINE, CENTRAL and Embase databases were used to search for relevant studies using the terms ' (sclerotherapy AND ulcer) OR (vein AND ulcer) OR (sclerotherapy AND vein)'. Heterogeneity between studies was quantified using the I² statistic. A random effects model was used to calculate risk ratios where substantial heterogeneity was found.ResultsThe initial search yielded 8266 articles. 8 studies were included in the qualitative synthesis and 3 in the meta-analysis. Superior complete ulcer healing rates were noted in patients treated with foam sclerotherapy versus compression therapy alone (pooled OR 6.41, 95% CI = 0.3–148.2, p = 0.246, random effects method). A marked degree of heterogeneity was observed between studies (I² = 81%).ConclusionA prospective, trial is warranted in order to determine the true merits of UGFS in the setting of venous ulceration.     

Endothermal heat-induced thrombosis after endovenous laser ablation: A single-center experience

Lower limb varicose veins are a common vascular disorder producing pain and disability when truncal vein reflux is present. Endovenous laser ablation (EVLA) of the great saphenous vein (GSV) is a safe and effective method for treating this condition. An unintended complication of this procedure is endothermal heat-induced thrombosis (EHIT) of common femoral vein. A retrospective outcomes analysis of patients who underwent EVLA of the GSV at King Khalid University Hospital from June 2006 to November 2018 was conducted to identify the risks factors and incidence of EHIT. Patients were assessed by clinical examination and duplex ultrasound imaging after the EVLA, and patient demographic characteristics and procedural factors predictive of EHIT were determined. Following EVLA, 11,070 duplex ultrasound examinations were performed for 1,230 limbs, and EHIT was detected in 65 (5.3%) limbs in 60 (6.8%) patients. Essentially all EHIT cases were detected in the first week (n = 63; 96.9%) and clot regression occurred over a period of 1–4 weeks. There were no significant differences in patient demographic characteristics or procedural factors between the EHIT and non-EHIT groups, except for the percentage of women (86% v 73%; P = .02), maximum GSV diameter (6.7 ± 2.7 mm v 6.0 ± 2.1 mm; P = .04), and percentage of patients with a competent saphenofemoral junction (41% v 37%; P < .001). EVLA is a safe treatment for great saphenous vein reflux, but EHIT can occur and was associated with female sex, large maximum GSV diameter, and competent saphenofemoral junction. Venous duplex imaging after EVLA is recommended because EHIT is asymptomatic in most patients.     

Comparative Study of Outcome of Duplex Ultrasound-Guided,Catheter-Directed Foam Sclerotherapy and Radio-frequency Ablation in the Management of Great Saphenous Varicose Veins

Chronic venous insufficiency of lower limbs is a common problem in adults. We compared the two modalities, namely duplex ultrasound-guided, catheter-directed foam sclerotherapy (UGFS) and radio-frequency ablation (RFA), in the management of great saphenous varicose veins using clinical assessment (Venous Clinical Severity Score, Venous Disability Score) and duplex imaging. Patients presenting with great saphenous vein (GSV) varicosity due to incompetent saphenofemoral junction (SFJ) were selected and randomly assigned in each arm, i.e., duplex UGFS group and RFA group. Patients were assessed on days 7, 30, and 90 both clinically and sonologically. Clinical assessment was based on the Venous Clinical Severity Score (VCSS) and Venous Disability Score (VDS). Obliteration of the treated GSV segment was noted in all the limbs of the RFA group (31/31) on duplex sonography on days 7, 30, and 90, while in the UGFS group, out of 30 limbs, obliteration was successful in 28 (28/30) and 2 had treatment failure. However, outcome of both the groups were statistically comparable (P value?>?0.05). After the procedure, improvement in the VCSS was noted in both the study arms in every follow-up and both the modalities were found to be equally effective. Improvement in the Venous Disability Score was there on every follow-up, but maximum improvement was seen on the second visit, i.e., post-treatment day 30. Improvement was statistically significant and equal in both arms after the initial 1 week. Foam sclerotherapy, especially catheter-directed, is as effective as radio-frequency ablation in achieving anatomical obliteration and yielding relief in clinical signs and symptoms in patients with GSV varicosity with SFJ incompetence.     

Multiple Small-Dose Injections Can Reduce the Passage of Sclerosant Foam into Deep Veins During Foam Sclerotherapy for Varicose Veins

ObjectiveTo compare the proportion of foam sclerosant that enters deep veins between multiple injections of <0.5 ml foam per injection and a few injections of >0.5 ml foam per injection.Design & methodsOne hundred and seven patients with superficial venous incompetence were randomised to receive either multiple injections of <0.5 ml 1% polidocanol (POL) -foam (multiple injections) or a few injections of >0.5 ml 1% POL-foam per injection (few injections) for the treatment of varicose tributaries. All patients then received ultrasound-guided foam sclerotherapy for refluxing great saphenous vein (GSV) using 3% POL-foam. Only a single session was allowed per patient in order to standardise treatment. Qualitative ultrasonographic inspection of the foam was carried out during a 5-min period before compression was applied. Post-sclerotherapy surveillance was done at day 3, 2 weeks, 1 month, 3 months, and 6 months.ResultsFifty-six limbs in 53 patients were treated with multiple injections and the remaining 56 limbs in 54 patients were treated with a few injections. There were no significant differences in age or male:female ratio between the groups. The mean volume of 1% POL-foam was 2.2 S.D. 0.6 ml (range: 0.7–4.0 ml) in the multiple injections group and 2.5 S.D. 0.6 ml (range: 1.0–4.0 ml) in the few injections group (p = 0.003). The mean volume of 3% POL was 1.5 ml (range: 0.7–3.0 ml) and 1.4 ml (range: 0.7–3.0 ml), respectively (p = 0.137). Ultrasonographic inspection immediately after sclerotherapy demonstrated that foam was distributed significantly more commonly in the deep veins of patients treated with a few injections (p = 0.0003). Two (4%) of the patients treated with a few injections developed migraine during the procedure, but recovered quickly with no further complications. There was no significant difference in the success rate between the groups at 6 months (p = 0.257).ConclusionsThese findings suggest that multiple small-dose injections can reduce the amount of foam sclerosant and the risk of foam sclerosant entering the deep veins in patients with superficial venous insufficiency.     

Endovenous Laser Ablation (EVLA) of the Anterior Accessory Great Saphenous Vein (AAGSV): Abolition of Sapheno-Femoral Reflux with Preservation of the Great Saphenous Vein

AimDuring surgery for sapheno-femoral junction (SFJ) and anterior accessory great saphenous vein (AAGSV) reflux, many surgeons also strip the great saphenous vein (GSV). This study assesses the short-term efficacy (abolition of reflux on Duplex ultrasound) of endovenous laser ablation (EVLA) of the AAGSV with preservation of a competent GSV in the treatment of varicose veins occurring due to isolated AAGSV incompetence.MethodThirty-three patients (21 women and 12 men) undergoing AAGSV EVLA alone (group A) and 33 age/sex-matched controls undergoing GSV EVLA (Group B) were studied. Comparisons included ultrasound assessment of SFJ competence, successful axial vein ablation, Aberdeen Varicose Vein Symptom Severity Scores (AVVSS) and a visual analogue patient-satisfaction scale.ResultsAt the 1-year follow-up, EVLA had successfully abolished the target vein reflux (AAGSV: median length 19 cm (inter-quartile range, IQR: 14–24 cm) vs. GSV: 32 cm (IQR 24–42 cm)) and had restored SFJ competence in all patients. Twenty of the 33 patients (61%) in group A and 14 of the 33 (42%) in group B (p = 0.218) required post-ablation sclerotherapy at 6 weeks post-procedure for residual varicosities. The AVVSS at 12 months follow-up had improved from the pre-treatment scores in both the groups (group A: median score 4.1 (IQR 2.1–5.2) vs. 11.6 (IQR: 6.9–15.1) p < 0.001; group B: median score 3.3 (IQR 1.1–4.5) vs. 14.5 (IQR 7.6–20.2), p < 0.001), with no significant difference between the groups. Patient-satisfaction scores were similar (group A: 84% and group B: 90%).Previous intervention in group A included GSV EVLA (n = 3) or stripping (n = 9). Thus, the GSV was preserved in 21 patients. The AVVSS also improved in this subgroup (4.4 (2.0–5.4) vs. 11.4 (6.0–14.1), p < 0.001) and SFJ/GSV competence was found to be restored at the 1-year follow-up.ConclusionsAAGSV EVLA abolishes SFJ reflux, improves symptom scores and is, therefore, suitable for treating varicose veins associated with AAGSV reflux.     

Duplex Ultrasound Outcomes Following Ultrasound-Guided Foam Sclerotherapy of Symptomatic Primary Great Saphenous Varicose Veins

ObjectivesTo describe duplex ultrasound (DUS) outcomes 12 months following ultrasound-guided foam sclerotherapy (UGFS) of primary great saphenous varicose veins (GSVV).MethodsA consecutive series of UK National Health Service patients underwent serial DUS examinations following UGFS with 3% sodium tetradecyl sulphate for symptomatic primary GSVV.Results344 treated legs (CEAP C_2/3 237, C₄ 72, C₅ 14, C₆ 21) belonging to 278 patients (103 male) of median age 57 (range 21–89) years were enrolled between November 2004 and May 2007. The median volume of foam used was 10 (range 2–16) ml. Above-knee (AK) and below-knee (BK) GSV reflux was present in 333 (96.8%) and 308 (89.5%) legs respectively prior to treatment. AK and BK-GSV reflux was completely eradicated by a single session of UGFS in 323 (97.0%) and 294 (95.5%) legs respectively; and by two sessions of UGFS in 329 (98.8%) and 304 (98.7%) legs respectively. In those legs where GSV reflux had been eradicated, recanalisation occurred in 18/286 (6.3%) AK and 23/259 (8.9%) BK-GSV segments after 12 months follow-up.ConclusionsA single session of UGFS can eradicate reflux in the AK and BK-GSV in over 95% of patients with symptomatic primary GSVV. Recanalisation at 12 months is superior to that reported after surgery and similar to that observed following other minimally invasive techniques.     

The Effect of Isolated Phlebectomy on Reflux and Diameter of the Great Saphenous Vein: A Prospective Study

ObjectivesTo evaluate the effect of phlebectomy on venous reflux and diameter of the great saphenous vein (GSV).DesignProspective cohort study.MethodPatients presenting with reflux in the GSV resulting in varicose veins were included in this series. Patients were treated by phlebectomy for dilated and incompetent tributaries of the GSV with conservation of the incompetent GSV. We measured reflux duration (RD), peak reflux velocity (PRV) and the diameter of the GSV using duplex ultrasound imaging at inclusion and 1 month after surgery.PatientsWe included 55 limbs in 54 patients (30 women and 24 men) aged from 37 to 83 (mean age 63) years.ResultsFollowing treatment we observed a significant reduction of the mean RD (0.81s vs. 1.5 s p < 0.01, t-test), mean PRV (120 mm s^?1 vs. 249 mm s^?1 p < 0.01, t-test) and mean diameter of the GSV (SFJ = 5.6 mm vs. 6.7 mm, p < 0.01, sub-terminal valve 4.8 mm vs. 4.4 mm p < 0.05, mid-thigh 5.0 mm vs. 4.2 mm, p < 0.01, knee 4.0 mm vs. 5.3 mm p < 0.01, mid-calf 2.7 mm vs. 4.0 mm, p < 0.01, t-test).ConclusionsWe noted reduced reflux in the GSV after phlebectomy with a significant reduction in RD and PRV. Phlebectomy also led to a significant reduction in GSV diameter. These data suggest that the haemodynamics and the diameter of the SV can be improved by using a treatment focussing on the saphenous tributaries.     

Long Cotton Wool Rolls as Compression Enhancers in Macrosclerotherapy for Varicose Veins

Background. Macrosclerotherapy in combination with compression has proven to be safe and effective in the treatment of varicose veins. Local compression is increased by pads, according to Laplace law. Firm rolls of cotton wool are fixed over the course of the entire vein to increase local compression and to reduce complications. Additional compression is given by a combination of a class I (daytime and nighttime) and class II (daytime only) medical compression hosiery.
Purpose. To evaluate the effectiveness and side effects of sclerocompression therapy with cotton wool rolls in combination with medical compression hosiery.
Method. Prospective study with 100 patients (120 legs) with primary varicose veins, which are treated with polidocanol as sclerosant with the empty vein technique. Immediately after the injection, a long cotton wool roll is placed over the entire vein and fixed. Additional compression is obtained with class I and class II medical compression hosiery. The interface pressure on the skin, just under the cotton wool roll, is measured on 12 legs with the aid of an interface pressure measuring instrument (Oxford Pressure Monitor).
Results. Good sclerosing results are obtained in all patients. Side effects are classified as early and late. In 16 patients, minor side effects which needed no treatment are observed. In only 3 cases (2.5%), intravascular blood clots (2) and phlebitis (1) needed incision and expression. The mean interface pressure of all measuring sensors under the cotton wool roll is 84 mm/Hg (68 to 122 mm/Hg).
Conclusion. This study proves the high effectiveness of a cotton wool roll compression right at the place of treatment. By using these long cotton wool compression rolls, the compression part of sclerocompression therapy becomes more effective and much easier to perform.     

Compliance with multidisciplinary team recommendations and disease outcomes in early breast cancer patients: An analysis of 4501 consecutive patients

BackgroundMultidisciplinary team (MDT) discussions are widely held to facilitate the diagnosis and treatment of breast cancer, but patient compliance with the MDT recommendations and the impact of compliance on disease outcome are uncertain.MethodsWe conducted a retrospective review of data from a prospective database of breast cancer patients treated at Shanghai Ruijin Hospital between April 2013 and August 2018. MDT discussions were held for all patients before they started adjuvant therapy. The patients were classified into compliant and non-compliant groups according to whether they received the MDT-recommended regimens. We also analyzed which clinicopathological factors were associated with compliance and prognosis.ResultsOf 4501 breast cancer patients, 3681 (81.8%) and 820 (18.2%) were included in the compliant and non-compliant groups, respectively. Age >70 years (P < 0.001), invasive ductal carcinoma (P < 0.001), and histological grade III (P = 0.011) were independently associated with higher risk of non-compliance, whereas Ki-67 labeling index ≥14% and history of benign breast disease were independently associated with compliance. Disease-free survival (hazard ratio [HR] 1.813, 95% confidence interval [CI] 1.367–2.405, P < 0.001) and overall survival (HR 2.478, 95% CI 1.431–4.291, P < 0.001) were worse in the non-compliant group.ConclusionsSeveral clinicopathological factors were associated with non-compliance with MDT recommendations for early breast cancer patients. Non-compliance was associated with worse disease outcome.     

Anatomical variations of donor portal vein in right lobe living donor liver transplantation: the safe use of variant portal veins

In right lobe (RL) living donor liver transplantation (LDLT), portal vein (PV) variations are of immense clinical significance. In this study, we describe in detail our PV reconstruction techniques in RL grafts with variant PV anatomy and evaluate the impact of accompanying biliary variations on the recipient outcomes. In a total of 386 RL LDLTs performed between July 2004 and July 2012, the clinical data on 52 (13%) transplants using RL grafts with variant PV anatomy were retrospectively analyzed. Portal vein anatomy was classified as type 2 in 20 patients, type 3 in 24 patients, and type 4 in eight patients. The PV reconstruction techniques utilized included back‐wall plasty (n = 21), back‐wall plasty with saphenous vein graft interposition (n = 6), saphenous vein graft interposition (n = 5), cryopreserved iliac vein Y‐graft interposition (n = 6), and quiltplasty (n = 3). There was no donor mortality. In a median follow‐up of 29 months, none of the recipients had vascular complications. Anomalous PV anatomy was associated with a high (54%) incidence of biliary variations; however, these variations did not result in increased biliary complication rate. Overall, the 1‐ and 3‐year patient survival rates of recipients were 91% and 81%, respectively. Vascular and biliary variations in RL grafts render LDLT technically more challenging. By employing appropriate reconstruction techniques, it is possible to successfully use RL grafts with PV variations without endangering recipient and donor safety.     

Portosystemic Shunt in Pediatric Living Donor Liver Transplant

BackgroundTo evaluate the significance of portosystemic shunts and associated long-term outcomes in living donor liver transplant (LDLT) among pediatric patients.MethodsRetrospective review of 121 pediatric patients who underwent LDLT between May 1994 and December 2015 at Taiwan Kaohsiung Chang Gung Memorial Hospital. Pre- and postoperative computed tomography images of the liver were reviewed, and portal vein complications were assessed.ResultsNinety-seven pediatric patients were included in the study, and 70 had portosystemic shunts before transplant. Thirty-three patients have portal systemic shunt (PSS) 6 months after transplant (mean [SD] shunt size, 4.59 [1.98] mm). Thirty-seven patients’ portosystemic shunts closed spontaneously (mean [SD] shunt size, 3.14 [1.06] mm). Smaller PSSs tend to close spontaneously with a cutoff point of 3.35 mm by receiver operating characteristic curve (P = .01). Patients with PSS have more portal vein complications than those without PSS (44.3% vs 11.1%, P = .02). Among PSS recipients, patients with portal vein complications tend to have larger PSS size (mean [SD], 4.14 [1.96] mm vs 3.59 [1.48] mm), although the difference is not statistically significant (P = .19).ConclusionsIn pediatric patients, preoperative portosystemic shunts are significantly correlated with portal venous complications, some of which require minimal interventions after LDLT with good outcomes. Shunts larger than 3.35 mm tend to persist after transplant with increased portal venous complications.     

Management of patch infections after carotid endarterectomy and utility of femoral vein interposition bypass graft

ObjectivePatch infection after carotid endarterectomy (CEA) is a rare but devastating complication. A variety of different treatment options are reported; however, there is currently no consensus on how to manage this highly morbid problem. The purpose of this study was to review our experience with management of infectious patch complications after CEA and to highlight utility of femoral vein interposition bypass grafting.MethodsAll CEA patch infection operations at the University of Florida from 2002 to 2017 were reviewed retrospectively. Preoperative history, intraoperative details, and postoperative complications were recorded. Bypass patency was verified with duplex ultrasound imaging (1 month, 6 months, annually). The primary end point was 30-day stroke or death; secondary end points included cranial nerve injury, reintervention, reinfection, and survival. Life tables were used to estimate end points.ResultsTwenty-nine patients (mean age, 70 ± 9 years; male, 76%) were identified. The index CEA occurred at a median of 15 months (interquartile range, 1-55 months) preoperatively (39% <2 months after the index procedure). A variety of patch materials were implicated (Dacron, n = 9; unknown/undocumented, n = 8; bovine pericardium, n = 5; expanded polytetrafluoroethylene, n = 3; unidentified nonbiologic prosthetic, n = 3; saphenous vein, n = 1). Carotid reintervention antecedent to the infected patch presentation occurred in 41% (incision and drainage, n = 10; carotid stent, n = 2; vein patch, n = 1). The most common infecting organisms were Staphylococcus and Streptococcus species (52%; n = 15). The most frequent presentation (46%; n = 13) was pericarotid abscess or phlegmon (pulsatile neck mass or pseudoaneurysm, 28% [n = 8]; carotid-cutaneous fistula, 28% [n = 8]). Reconstruction strategy included femoral vein interposition bypass in 24 patients (83%; nonreversed configuration, 16/24 [67%]), saphenous vein patch in 4 patients (14%), and femoral vein patch in 1 patient (3%). Median postoperative length of stay was 5 days (interquartile range, 4-8 days). Twelve patients (41%) experienced a complication, and the 30-day stroke/death rate was 7% (death, n = 1; stroke, n = 1). The single postoperative death occurred in a patient with history of congestive heart failure who developed a pulseless electrical activity arrest on postoperative day 11 that resulted in multiorgan system failure. Cranial nerve injury occurred in 28% (n = 8; cranial nerves X [3], VII [2], XII [2], and IX [1]), all of which resolved by last follow-up. In follow-up (mean clinical follow-up, 17 ± 14 months; mean survival time, 108 months [95% confidence interval, 81-135 months]), two (7%) complained of limb edema with femoral cutaneous nerve palsy that resolved by 3 months. One interposition bypass occluded at 3 months (asymptomatic); the remaining grafts remained patent with no restenosis, reinfection, or reintervention events. The 1- and 5-year survival was 87% ± 6% and 82% ± 8%, respectively.ConclusionsCEA patch infection can be successfully managed with femoral vein interposition bypass with acceptable postoperative outcomes. Excellent patency can be anticipated with good long-term survival. This strategy can be considered especially in cases with carotid size mismatch or if there is limited availability of alternative biologic conduits.     

Predictive factors for fracture-related infection in open tibial fractures in a Sub-Saharan African setting

IntroductionThe management of open tibial fractures (OTF) is challenging in low and middle-income countries (LMICs) where appropriate human resources and infrastructure (including equipment, implants and surgical supplies) are not readily available and medical care is not readily accessible. OTF are not rarely associated with a subsequent fracture-related infection (FRI), which is one of the most devastating and difficult to cure complications in orthopaedic trauma care. The aim of this study was to determine the rate and the predictive factors of FRI in OTF in a limited-resource setting of sub-Saharan Africa.MethodsPatients with OTF who underwent surgery from July 2015 to December 2020 and followed-up for at least 12 months in a tertiary care teaching hospital in Yaoundé (Cameroon) were retrospectively investigated. Diagnosis of FRI was based on the confirmatory criteria of the International FRI Consensus definition. All patients with bone infections, occurring at any time point during follow-up, were included. Logistic regression was used to determine the predictive factors for FRI.ResultsOne hundred and five patients with OTF were studied. With a mean follow-up period of 29.5 ± 16.6 months, 33 patients (31.4%) presented with FRI. Gustilo-Anderson type of OTF, compliance with antibiotics, blood transfusion, time to first washing of the wounds and method of bone fixation were factors associated with the occurrence of FRI. In multivariable logistic regression, 6-hours delay to first washing of the wounds (OR=8.07, 95% CI: 1.43–45.31, p = 0.01), and compliance with antibiotics (OR=11.33, 95%CI: 1.11–115.6, p = 0.04) were the only independent predictors of FRI.ConclusionThe overall rate of FRI in open tibial fracture is still high in the sub-Saharan African context. For similar low-resources settings, this study supports the recommendations (1) to perform a very early washing-dressing-splinting of OTF on admission of the patient, (2) to administer antibiotics early, and (3) to perform surgery as soon as reasonably possible, once appropriate personnel, equipment, implants and surgical supplies are available.     

Intraoperative vascular mapping improves patient eligibility for arteriovenous fistula creation

BackgroundWe assessed the utility of intraoperative vein mapping performed by the operating surgeon for evaluating vessel suitability for arteriovenous fistula (AVF) creation.MethodsIn a retrospective review of 222 AVFs, vein diameter measurements were compared between intraoperative and preoperative mapping in the same anatomical location. AVF creation was based on intraoperative vein diameter ≥2 mm, using a distal to proximal and superficial veins first approach. Potential selection of access type based on preoperative findings alone was analyzed.ResultsThe mean diameter of the veins used for AVF creation measured 3.6 ± 0.8 mm on intraoperative duplex versus 2.5 ± 0.9 mm when the same veins were measured on preoperative duplex. Based on preoperative mapping alone, 23% of patients would have received a more proximal AVF and 5% would have needed a graft. AVFs created more distally based on intraoperative findings had similar maturation rates compared to the rest of the cohort, 79% versus 84% (p = 0.2).ConclusionsIntraoperative vein mapping can be used to evaluate vessel suitability for AVF and compared to pre-operative vein mapping may increase the eligibility of distal veins for fistula creation while reducing the need for AV grafts.