Great Saphenous Vein Diameter at the Saphenofemoral Junction and Proximal Thigh as Parameters of Venous Disease Class

BackgroundGreat saphenous vein (GSV) incompetence is involved in the majority of cases of varicose disease. Standardised pre-interventional assessment is required to analyse the relative merit of treatment modalities. We weighed GSV diameter measurement at the sapheno-femoral junction (SFJ) against measurement at the proximal thigh 15 cm distal to the groin (PT), established a conversion factor and applied it to selected literature data.MethodsLegs with untreated isolated GSV reflux and varices limited to its territory and control legs were studied clinically, with duplex ultrasound and photoplethysmography. GSV diameters were measured at both the SFJ and the PT. A conversion factor was calculated and used to compare published data.ResultsOf 182 legs, 60 had no GSV reflux (controls; group I), 51 had above-knee GSV reflux only (group II) and 71 had GSV reflux above and below knee (group III). GSV diameters in group I measured 7.5 mm (±1.8) at the SFJ and 3.7 mm (±0.9) at the PT. In groups II and III, they measured 10.9 mm (±3.9) at the SFJ and 6.3 mm (±1.9) at the PT (p < 0.001 each). Measurement at the PT revealed higher sensitivity and specificity to predict reflux and clinical class. Good correlation between sites of measurement (r = 0.77) allowed a conversion factor (SFJ = 1.767 * PT, PT = 0.566*SFJ) to be applied to pre-interventional data of published studies.ConclusionsGSV diameter correlates with clinical class, measurement at the PT being more sensitive and more specific than measurement at the SFJ. Applying the conversion factor to published data suggests that some studies included patients with minor disease.     

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.     

Great Saphenous Vein Sparing Surgery by Angioscopic Valvuloplasty Combined with Axial Transposition of a Competent Tributary Vein – 5-Year Follow-Up

ObjectiveTo evaluate the efficacy and haemodynamic effects of great saphenous vein (GSV) sparing surgery – valvuloplasty combined with axial transposition of a competent tributary vein (A-VACT).Materials and methodsEighty-five limbs in 74 patients with isolated GSV incompetence were selected for GSV sparing surgery. After angiographic valvuloplasty, the competent tributary vein was exposed and cut 1.5 cm distal to its insertion point on the GSV. The transected vein was anastomosed end-to-side to the GSV, which was ligated between the tributary insertion site and the anastomosis. Venous valve competence were screened by serial postoperative duplex examination, and venous haemodynamic changes were analyzed using venous filling index (VFI) measured by air plethysmograph pre- and postoperatively. The follow-up period was 5-years.ResultsSixty-seven patients were included in whom 76 limbs were treated. There was a statistically significant reduction in the vein diameter at the SFJ after 5-years (0.83 S.D. 0.29 cm to 0.46 S.D. 0.12 cm, p = 0.0002, Wilcoxon). Similarly, significant reduction was found in the GSV at the 5-year follow-up point (0.63 S.D. 0.19 cm to 0.39 S.D. 0.11 cm, p < 0.0001, Wilcoxon). On the other hand, there was significant increase in the diameter of the competent tributary vein postoperatively (0.22 S.D. 0.13 cm to 0.31 S.D. 0.12 cm, p < 0.0001, Wilcoxon). Duplex scanning demonstrated reflux at the SFJ in 12 limbs (16%). Similarly, in the GSV, venous reflux was found in 13 limbs (17%). Reflux in the transposed tributary vein was found in 20 limbs (26%). But only 7 limbs (9%) had minor varicose veins' recurrence. VFI remained normal during the follow-up examination. The preoperative VFI confirmed the presence of venous reflux, but there were significant improvement in the VFI values at all postoperative examinations.ConclusionsA-VACT procedure improves venous function, resolves varicose veins at 5-years follow-up as well as preserving the GSV for future grafting.     

Comparison of dynamic changes in aortic diameter during the cardiac cycle measured by computed tomography angiography and transthoracic echocardiography

ObjectiveThis study aimed to examine the relationship between dynamic changes in aortic diameter and corresponding measurement methods.MethodsConsecutive adult (nonaneurysmal) patients being surgically treated for heart disease (mean age, 51 ± 11 years; range, 29-76 years; N = 25) were included in this study. All patients underwent transthoracic echocardiography (TTE), computed tomography angiography (CTA), and intraoperative ultrasound (IOUS). Anteroposterior diameters were measured at 1 cm above the junction of the aortic sinus, the proximal 1 cm of the innominate artery, and the midpoint of the two.ResultsThe average diameter of the proximal ascending aorta in systole/diastole measured by IOUS was 32.07 ± 2.03/30.27 ± 2.05 mm (paired t-test: difference, 1.80 ± 0.46 mm; P < .001). The average diameters of the proximal ascending aorta measured by nonelectrocardiography-gated CTA and TTE were 31.45 ± 1.97 mm and 29.7 ± 1.84 mm, respectively. The average diameter of the mid and distal ascending aorta in systole/diastole measured by IOUS was 32.35 ± 1.95/30.57 ± 1.94 mm (paired t-test: difference, 1.78 ± 0.44 mm; P < .001) and 32.32 ± 1.92/30.67 ± 1.90 mm (paired t-test: difference, 1.65 ± 0.42 mm; P < .001), respectively. The average diameter of the mid and distal ascending aorta measured by CTA was 31.74 ± 1.92 mm and 31.59 ± 1.96 mm, respectively. At each location, the difference in the aortic diameter between systole and diastole was statistically significant (all P values <.001; paired t-test). The minimum and maximum changes in the diameter between systole and diastole were 0.90 mm and 2.70 mm. In all, 96% (24/25) of the average diameters derived from IOUS and CTA at the three locations were within the concordance limit in systole, and 92% to 100% (23/25 to 25/25) were within the concordance limit in diastole. The average diameters derived from IOUS and TTE images of the proximal ascending aorta were within the bounds of the concordance limit 92% (23/25) of the time in systole and 100% (25/25) of the time in diastole. The average diameters derived from CTA and TTE images of the proximal ascending aorta were within the bounds of the concordance limit 88% (22/25) of the time. Pearson correlation coefficients between these groups ranged from 0.905 to 0.982 (all P values <.01).ConclusionsThe ascending aorta diameters measured by nonelectrocardiography-gated CTA and TTE were consistent with the IOUS measurements.     

Physiological Changes in Venous Hemodynamics Associated with Elective Fasciotomy

It has been postulated that lower extremity fasciotomy may disrupt the calf musculovenous pump and predisposes to development of chronic venous insufficiency (CVI). However, studies based on trauma patients who undergo emergent fasciotomy are confounded by the possibility of concomitant vascular and soft tissue injury and use historical controls. This is a prospective study that evaluates venous hemodynamics in young patients undergoing elective fasciotomy for chronic exertional compartment syndrome (CECS), eliminating the problems associated with retrospective study of trauma patients. CECS was diagnosed by history and, when indicated, measurement of compartment pressures. Prior to elective two- or four-compartment fasciotomy, each patient underwent lower extremity air plethysmography (APG) and colorflow duplex ultrasonography. These studies were repeated a minimum of 6 weeks postoperatively. Fifteen patients who had fasciotomies for CECS were studied; two of these patients had bilateral fasciotomies for a total of 17 limbs. There were 13 male and two female patients (average age 31.2 years). APG and colorflow duplex were performed an average of 12 weeks after fasciotomy. Outflow fraction, venous volume, and ejection volume showed no significant changes postoperatively. However, the venous filling index (VFI) increased (0.9 ± 0.1 vs. 1.1 ± 0.1 mL/sec; p < 0.05, paired t-test), the ejection fraction tended to decrease (59 ± 4% vs. 52 ± 2%; p < 0.08, paired t-test), and the residual volume fraction (RVF) increased (26 ± 3% vs. 36 ± 5%; p < 0.05, paired t-test). There were no patients with evidence of deep venous reflux. Two extremities with preoperative greater saphenous vein (GSV) reflux did not worsen, and three extremities developed new GSV reflux following fasciotomy, although VFI remained normal in each extremity. Elective fasciotomy for CECS does not lead to significant venous reflux but likely does diminish calf muscle pump function and increases RVF moderately in young adult patients. With longer follow-up this diminished calf muscle pump function may increase the risk of CVI.     

When to take it out? Optimal timing of interval appendectomy in 500 consecutive children

Purpose: While interval appendectomy following nonoperative management of perforated appendicitis is delayed until several weeks after presentation, the optimal time from presentation to interval appendectomy is unknown.Methods: The data warehouse of a large children's hospital was queried for interval appendectomies from 2006 to 2019. Data extracted included demographics, initial and operative hospitalization details, and pathology findings. Student's t-test and logistic regression were used where appropriate.Results: 500 patients were identified with a mean age of 10 years, 53% male. Mean time to operation was 12.7 weeks. Operation prior to 12 weeks was associated with increased odds of acute inflammation on pathology (OR = 2, p < 0.01). Acute inflammation was associated with increased mean operative time (101 vs 84 min, p < 0.01). Presence of an appendicolith, initial hospitalization length, drain placement, readmission prior to operation, age and gender were all non-predictive of acute inflammation. Only 11% of appendices had an occluded lumen and 17% an appendicolith. Carcinoid tumors were identified in 6 patients (1.2%).Conclusion: Acute inflammation is found many weeks after perforation and is associated with increased operative time. Acute inflammation is more likely to be present in operations performed prior to 12 weeks.     

Carotid endarterectomy saphenous vein patch rupture revisited: Selective use on the basis of vein diameter

Purpose: The single major disadvantage of carotid endarterectomy (CEA) patch reconstruction with greater saphenous vein (GSV) is central patch rupture, which has a reported incidence of 0.5% to 4%. This is a prospective evaluation of the selective use of GSV for a CEA patch based on previously established vein diameter criteria.Methods: Between 1988 and mid-1995, 534 of 671 CEAs (80%) were reconstructed with GSVs that had a distended diameter ≥3.5 mm. Thigh veins were used in all 252 women who underwent CEA. Of the 282 men who underwent CEA, 265 GSVs (94%) were harvested from below the knee and 17 from the thigh. During this period four thigh and 13 below-knee veins (3.2%) were rejected because the diameter was <3.5 mm, and a synthetic patch was used instead. In 408 of the CEAs with GSV (76%) the vein rupture pressures and diameters were measured, the CEA geometry was measured, and the predicted CEA vein patch rupture pressures were calculated.Results: No GSV patches ruptured in this series. This compares favorably with three patch ruptures in 239 previous CEAs when no vein diameter criteria was used ( p = 0.03). This also compares favorably with a multicenter series of 13 GSV patch ruptures (0.73%) in 1773 CEAs ( p = 0.03) and with a single-center series of eight ruptures (0.47%) in 1699 CEAs ( p = 0.05) . GSV diameters were 4.9 ± 0.9 mm (mean ± 1 SD); vein rupture pressures, 3.9 ± 1.5 atmospheres; carotid bulb major axis diameters, 12.5 ± 1.6 mm; carotid bulb maximum diameters of curvature, 14.2 ± 2.2 mm; and CEA patch rupture pressures, 1.3 ± 0.6 atmospheres (range, 280 mm Hg to 4 atmospheres). CEA vein patch rupture pressure correlates positively with vein diameter ( p < 0.001, slope), but there is wide variability (correlation coefficient = 0.39). The 14 CEAs (3.4%) with predicted rupture pressures <400 mm Hg were performed with veins 3.5 to 5.5 mm in diameter (mean, 4.2 mm), and all had carotid bulb major axis diameters >12 mm (mean, 15.3 mm). Eight of these CEAs were reconstructed with thigh veins.Conclusions: Use of GSVs with a distended diameter ≥3.5 mm for CEA patch reconstruction significantly reduces the probability of central patch rupture; however, a few CEAs reconstructed with veins >3.5 mm in diameter and large carotid bulbs have predicted patch rupture pressures <400 mm Hg. Because at times some veins will have rupture pressures lower than desirable, CEA reconstruction should be tailored to keep the carotid bulb major axis diameter <13 mm. (J Vasc Surg 1996;24:346-52.)     

Manual mobilization of the wrist: A pilot study in rehabilitation of patients with a chronic hemiplegic hand post-stroke

Study designProspective pilot cohort study, quasi-experimental design.IntroductionRestricted hand mobility, limitation in activities and participation, due to relative immobilization of the hemiplegic hand are frequently reported after stroke.Purpose of the studyTo establish whether manual mobilization of the wrist has an additional value in the treatment of the hemiplegic hand.MethodsEighteen patients received treatment twice a week for a period of 6 weeks. Both treatment groups received therapy based upon the Dutch guidelines for stroke. In the intervention group, a 10-min manual mobilization of the wrist was integrated. The primary outcomes were active and passive wrist mobility and activity limitation. The secondary outcomes were spasticity, grip strength, and pain. Data were collected at 0, 6 and 10 weeks. Statistical analysis was performed using the Friedman's test, related t-test, Wilcoxon test, independent t-test, and Mann–Whitney U-test.ResultsStatistically significant differences were found in the intervention group; between T0 and T2 measurements in active wrist extension (+18°; p < 0.001), in passive wrist extension (+15°; p < 0.001), and in the Frenchay Arm Test (+2 points, 18%; p = 0.038). This significant improvement was not found in the control group. Statistically significant differences were found between the two groups in active and passive wrist extension (p < 0.001; p = 0.002), as well as a change in Frenchay Arm Test (p = 0.01).ConclusionThis study suggests that manual mobilization of the wrist has a positive influence on the recovery of the hemiplegic hand. Replication of the results is needed in a large scale randomized controlled trial.Level of evidence4.     

A radiographic zone-based approach to predict meniscus injury in lateral tibial plateau fracture

ObjectivesThere is limited data regarding meniscal injury and it's association to fracture location and articular impaction/displacement (AID) in tibial plateau fractures. The purpose of this study was to predict lateral meniscal injury in tibial plateau fractures, based on location and extent of AID as visualized on pre op CT images.DesignRetrospective review study.SettingLevel I academic trauma center.PatientsWe retrospectively reviewed lateral tibia plateau fracture patients that were treated operatively using CPT codes 27535 and 27536. Two hundred patients were identified. Inclusion criteria were lateral tibia plateau fracture, age of 18 years or older, and documented direct examination of lateral meniscus integrity intraoperatively. Seventy patients met inclusion criteria.InterventionThe injured lateral tibial plateau was divided into four quadrants on pre-operative CT and maximum AID was measured. The zone of fracture was defined as the location of largest AID (Image-1). All patients had an arthrotomy at the time of surgery to evaluate the integrity of the meniscus. Intra operative data regarding meniscal integrity and preoperative CT data were analyzed. Logistic regression was used to estimate what effect zone and amount of AID had on predicting the meniscal injury. Receiver operating characteristic (ROC) analysis was performed to determine cut off points for high sensitivity/specificity.Main outcome measurementsAmount and area of depression in the lateral tibial plateau as relates to meniscal injury.ResultsMean age was (45.1 ± 12.9) years. Twelve had Schatzker type I and 58 had type II fractures. Twenty-two patients had meniscus injury (MI) and forty-eight patients did not have a meniscus injury (NMI). Mean AID for MI was 12.48 mm ± 7.17 mm and 6.4 mm ± 4.3 mm for NMI (p<0.01). In MI group, largest AID was in Posterolateral (PL) zone(17.58 mm ± 8.9 mm) followed by Anteromedial (AM) zone (13.3 mm ± 7.2 mm) and Anterolateral (AL) zone (9.4 mm ± 5.8 mm). In NMI group largest AID was in AL zone (8.52 mm ± 2.6 mm) followed by AM zone (8.04 mm ± 5.4 mm) and PL zone (7.75 mm ± 2.35 mm). Patients with PL zone involvement had a lower meniscus tear rate compare to other zones. Logistic regression revealed that for every 1 mm increase in AID there is a 21% increase chance of meniscus tear (p<0.01). Comparison of the zones indicated that for the same AID, AL and AM zone fractures have 7.3 and 5.6 times increase risk of meniscus tear, respectively, as compared to PL zone (p<0.05). ROC analysis revealed that AID of 4.3 mm as a cut off point provides 100% sensitivity for diagnosis of meniscus tear.ConclusionWith 1 mm increase in AID there is a 21% increase in chance of meniscal tear. With the same AID, AL and AM zone fractures have a significantly higher chance of having a meniscal tear. AID of 4.3 mm provides 100% sensitivity to predict meniscal tear in lateral tibia plateau fracture. These values are useful in predicting pre op meniscal tear without MRI.     

Outcomes following lung re-transplantation in patients with cystic fibrosis

PurposeWe examined cystic fibrosis (CF) patients and compared their clinical status at the time of primary versus double lung re-transplantation (re-DLTx) in order to better understand lung retransplant practice patterns.MethodsWe performed a retrospective analysis of the UNOS Database identifying CF patients ≥18 years old undergoing re-DLTx (5/4/2005 and 12/4/2020). Baseline and clinical variables at the primary and re-DLTx were compared utilizing the paired student t-test. Graft survival was defined as time from surgery to retransplant and analyzed using Kaplan-Meier estimates.Results277 CF patients who underwent re-DLTx experienced a significantly worse 5-year survival when compared to the primary DLTx cohort (47.9% vs 58.8%, p = 0.00012). The following differences were observed comparing CF re-DLTx group to their primary DLTx: higher LAS score at the time of listing (50.66 vs 42.15, p < 0.001) and transplant (62.19 vs 48.20, p < 0.001), and increase LAS from the time of listing to transplant (+12.22 vs +7.23, p = 0.002). While serum albumin and total bilirubin were similar, CF patients had a higher creatinine (1.05 vs 0.74, p < 0.001), dialysis (4.4% vs 0.6%, p < 0.001), ECMO bridge to transplant rates (7.6% vs 4.0%, p < 0.001), and higher oxygen requirements (5.95 vs 3.93, p < 0.001) at the time of listing for a re-DLTx.ConclusionCompared to their initial transplant, CF patients experience significant clinical decline in renal, cardiac, and pulmonary function at the time of lung retransplantation. This may indicate that an earlier evaluation and rehabilitation process may be necessary to identify patients earlier for lung retransplantation prior significant clinical decline.     

Comparison of laparoscopic percutaneous extraperitoneal closure and laparoscopic intracorporeal suture in pediatric hernia repair

BackgroundLaparoscopic inguinal repair use is rapidly growing because it is a minimally invasive surgery (MIS) technique. However, there is insufficient evidence to support the use of one MIS over others. We compared laparoscopic intracorporeal suture (LIS) and laparoscopic percutaneous extraperitoneal closure (LPEC) to determine which technique is superior.MethodsBetween February 2017 and December 2019, 260 children who underwent LPEC and 214 children who underwent LIS were enrolled. Operative time, recovery score, and patient cosmetic satisfaction were compared. A total of 108 propensity score-matched pairs were analyzed using paired t-test for continuous measurements and McNemar test for categorical variables.ResultsThe mean surgery time was lower in the LPEC group for both unilateral (15.76 ± 5.35 vs. 19 ± 5.71 min; p = 0.04) and bilateral (21.56 ± 5.7 vs. 26.38 ± 6.94 min; p = 0.01) surgeries. The LPEC group required shorter time for complete recovery (p = 0.017). The mean rating for scar visibility was higher in the LIS group (p = 0.02); however, both groups had high levels of cosmetic satisfaction (p = 0.125).ConclusionLPEC for hernia repair is safe and efficient in children and reduced operative time, hastened recovery, and provided excellent cosmetic results.     

Comparison of 980 nm Laser and Bare-tip Fibre with 1470 nm Laser and Radial Fibre in the Treatment of Great Saphenous Vein Varicosities: A Prospective Randomised Clinical Trial

ObjectivesThe aim of this study is to compare efficacy, early postoperative morbidity and patient comfort of two laser wavelengths and fibre types in treatment of great saphenous vein (GSV) incompetence resulting in varicosities of the lower limb.DesignProspective randomised clinical trial.Materials and MethodsSixty patients (106 limbs) were randomised into two groups. They were treated with bare-tip fibres and a 980 nm laser in group 1 and radial fibres and 1470 nm laser in group 2 in order to ablate the GSV. Local pain, ecchymosis, induration and paraesthesia in treated regions, distance from skin, vein diameter, treated vein length, tumescent anaesthesia volume, delivered energy and patient satisfaction were recorded. Follow-up visits were planned on the 2nd postoperative day, 7th day, 1st, 2nd, 3rd and 6th months.ResultsMean GSV diameters at saphenofemoral junction and knee levels were 12.1 S.D. 4.3 mm and 8.2 S.D. 2.4 mm, and 11.8 S.D. 4.1 mm and 7.9 S.D. 2.6 mm respectively in groups 1 and 2. There were 14 patients with induration, 13 with ecchymosis and nine minimal paraesthesia in group 1 and no or minimal local pain, minimum ecchymosis or induration in group 2. Duration of pain and need for analgesia was also lower in group 2 (p < 0.05). There was significant difference on postoperative day 2, day 7 and 1st month control in favour of group 2 in venous clinical severity scores (VCSS).ConclusionTreatment of the GSV by endovenous laser ablation using a 1470 nm laser and a radial fibre resulted in less postoperative pain and better VCSS scores in the first month than treatment with a 980 nm laser and a bare-tip fibre.     

Oestradiol Levels in Varicose Vein Blood of Patients with and without Pelvic Vein Incompetence (PVI): Diagnostic Implications

PurposeTo assess the difference in the oestradiol levels of blood taken from varicose veins in patients with and without pelvic vein incompetence (PVI).Materials and methodsWomen of child-bearing age with symptomatic primary or recurrent varicose veins of the great saphenous vein (GSV) were included in a prospective study. Patients underwent duplex ultrasonography and pelvic vein phlebography. They were divided into a group with PVI (PVI group) and a control group with GSV reflux alone (VV group). Blood samples were collected from the GSV at the sapheno-femoral junction or lower in the thigh as well as from the arm. Oestradiol levels were determined by electroluminescence.ResultsBetween January and December 2007, 40 women were studied, of which 19 showed phlebographic evidence of PVI (PVI group), while 21 were included in the VV group. Phlebography revealed an incompetent ovarian vein in 14 (74%) patients of the PVI group, dilated uterine and ovarian plexuses in 12 (63%) and an incompetent internal iliac vein in six cases (32%). In the PVI group, the median oestradiol level in GSV samples was 121 pg ml^?1 (range: 12–4300), while in the VV group the median level was 75 pg ml^?1 (range: 9–1177). In the upper limb, the PVI group patients had a median level of 78 pg ml^?1 (range: 15–121) and the VV group patients 68 pg ml^?1 (range: 13–568). The ratio of lower limb/upper extremity was significantly higher (p < 0.002) in patients of PVI group (median: 1.9; range: 0.7–33) than in those of the VV group (median: 1.1; range: 0.8–13). A threshold ratio of 1.4 showed the highest combined sensitivity and specificity in differentiating patients with PVI from those without.ConclusionsIn patients with varicose veins arising from the GSV, oestradiol levels were significantly higher in the lower limb than in the upper extremity in the subgroup with associated PVI. It may be possible to use this observation as a diagnostic test in patients with suspected PVI. This deserves further study.     

Varicose vein surgery with preservation of the saphenous vein: A comparison between high ligation-avulsion versus saphenofemoral banding valvuloplasty-avulsion

Purpose: Surgical treatment of varicose veins with preservation of the greater saphenous vein (GSV) was studied.Methods: Patients with reflux at the saphenofemoral junction and grossly normal GSV were treated with two different surgical techniques: perivalvular banding valvuloplasty (PVBV-A) of the saphenous valve, wherein the diameter of the uppermost saphenous valve was narrowed by Dacron-reinforced silicone band (12 patients, 15 extremities); and high ligation (HL-A) of the saphenous vein, wherein the GSV was ligated flush with the femoral vein (14 patients, 16 extremities). Both groups also had varicose tributaries of GSV avulsed through multiple stab incisions.Results: In the HL-A group two GSV (13%) remained completely patent, 10 GSV (62.5%) thrombosed partially, and the remaining four GSV (25%) had complete thrombosis. In the PVBV-A group 12 GSV (80%) remained completely patent and without reflux, one GSV (7%) remained patent but showing reflux. Two GSV (13%) thrombosed completely. There were no surgical complications or recurrences (mean follow-up was 9.4 months for PVBV-A and 9.5 months for HL-A), and the postoperative recovery time was similar for both groups.Conclusions: Both techniques are equally effective in the early elimination of varicosities. Preservation of the saphenous vein is significantly better after PVBV-A (p < 0.01). A prospective randomized trial with long-term follow-up is required. (J VASC SURG 1994;20:684-7.)     

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.     

Real-world cost analysis of endovascular repair versus open repair in patients with nonruptured abdominal aortic aneurysms

BackgroundThe aim of this study was to provide a nationwide, all-payer, real-world cost analysis of endovascular aortic aneurysm repair (EVAR) versus open aortic aneurysm repair (OAR) in patients with nonruptured abdominal aortic aneurysms (non-rAAA).MethodsAll non-rAAA patients registered between July 2009 and March 2015 in the Premier Healthcare Database were analyzed. The Student t-test and the χ² test were used for continuous and categorical variables, respectively; median value comparisons were done with the Wilcoxon-Mann-Whitney rank-sum test. The in-hospital absolute mean total cost (sum of fixed cost and variable cost) and subcategories were analyzed after adjustment for inflation at July 2015. Fixed costs included all overhead costs while variables costs included in-hospital services including procedures, room and board, services provided by hospital staff, and pharmacy costs. Total cost was stratified based on admission type (emergency vs nonemergency), 75th percentile of length of hospital stay among individual procedures (expected vs extended stay), mortality, and complications. Student t-test and Fisher's analysis of variance were used for comparing mean cost. Year-wise comparison of mean cost was done with analysis of variance to look for a trend over time.ResultsOur study cohort included 38,809 non-rAAA patients (33,171 EVAR and 5638 OAR). The mean total cost of index admission was lower in EVAR in comparison with OAR ($32,052 vs $36,091; P < .001), with lower fixed costs ($11,309 vs $16,818; P < .001) and higher variable costs ($20,743 vs $19,272; P < .001). Cost of pharmacy, labor, operating room, room and board and other costs were significantly higher with OAR, whereas the supply cost was higher with EVAR. The expected hospital length of stay of patients who underwent EVAR was associated with a higher total cost ($27,271 vs $25,680; P < .001) and a higher variable cost ($18,186 vs $13,671; P < .001) than OAR patients. However, the extended hospital stay of patients who underwent EVAR had lower costs in all categories compared with the extended length of stay of those who underwent OAR. Mortality associated with EVAR was costlier than OAR associated mortality (mean $72,483 vs $59,804; P = .017). From 2009 to 2014, the mean total cost of EVAR increased significantly by 18.5% ($28,745 vs $34,049; P < .001) owing to a 7.8% increase in fixed costs ($10,931 vs $11,789; P < .001) and a 25.0% increase in variable costs ($17,804 vs $22,257; P < .001). The mean total cost OAR remained stable over time.ConclusionsOverall hospitalization costs associated with EVAR of non-rAAA was lower than the hospitalization cost of OAR. Interestingly, we found that, among patients who had an expected hospital length of stay, the hospitalization cost after OAR was significantly lower than after EVAR. The average hospitalization cost of OAR was stable during the 5 years study period, whereas the hospitalization cost of EVAR increased significantly over time. Further studies are required to identify reasons for increased costs associated with EVAR.     

The value of compassion: Healthcare savings of palliative care consults in trauma

BackgroundThe effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear.Study DesignWe interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared.Results140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01).  Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01).  Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01).  Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01).  Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group.  Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01).  Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01).ConclusionExpert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.     

Venous reflux and venous distensibility in varicose and healthy veins.

OBJECTIVES: The aim of this study was to analyse venous diameter changes and venous reflux parameters, assessed during a standardised Valsalva manoeuvre in healthy subjects and in patients with varicose veins. METHODS: Measurements were carried out in 444 vein segments, (96 legs of 48 healthy volunteers, 52 legs of 35 patients with varicose veins). The common femoral vein (CVF), the femoral vein (FV) and the great saphenous vein (GSV) were investigated. The parameters of reflux and the relative venous diameter change (VD diff %) were measured simultaneously during a standardised Valsalva manoeuvre. RESULTS: Venous diameter changes during Valsalva manoeuvre (VD diff) were significantly greater in the GSV and in the deep veins of varicose patients compared to healthy subjects. The median (Interquartile range) of VD max in the CFV was: 13.1 (3.5) mm and 11.2 (3.4) mm (p=0.0002, Mann-Whitney - U test), in the FV 7.8 (2.7) mm and 6.9 (2.0) mm (p=0.01, Mann-Whitney), in the GSV: 7.3 (3.7) mm and 4.2 (1.1) mm (p<0.0001, Mann-Whitney) for the varicose and healthy veins respectively. Good correlation was seen for the retrograde peak reflux velocity (PRV) and VD diff % in varicose veins (r=0.71 (0.57 - 0.81) p<0.0001, Mann-Whitney). CONCLUSION: Relative venous diameter--changes during a standardised Valsalva manoeuvre are significantly larger in the deep and superficial veins of varicose vein patients compared with healthy veins, the increased distensibility correlates with venous reflux parameters in varicose vein patients.     

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.