Saphenous vein rupture pressure, rupture stress, and carotid endarterectomy vein patch reconstruction

Early postoperative patch rupture is a catastrophic complication of carotid endarterectomy reconstruction with greater saphenous vein. Mechanical determinants of saphenous vein rupture were identified by structural measurements and the results applied to carotid endarterectomy patch geometry. Diameter and rupture pressure was measured in fresh saphenous vein segments from the ankle, knee, or thigh in 157 patients undergoing bypass operations. Circumferential hoop rupture stress was calculated and the results were applied to 157 carotid endarterectomy reconstructions. All vein ruptures were in the cylindric axis. The mean vein diameter was 4.58 mm. The mean vein rupture pressure was 2873 mm Hg (3.78 atm). Vein diameter was larger in the thigh than in the ankle or knee (p less than 0.01), but there was no significant difference in rupture pressure between veins from the three locations. Women had a smaller vein diameter than had men at all locations (p less than 0.01). There was a positive linear correlation between vein diameter and rupture pressure. The mean maximum diameter of curvature of 157 carotid endarterectomy reconstructions with a vein patch was 13.3 mm. Multiple random applications of the 157 veins to 157 carotid diameters predicted a mean patch rupture pressure of 1087 mm Hg (1.43 atm), 1163 mm Hg (1.53 atm) for men, and 866 mm Hg (1.14 atm) for women. Predicted vein patch rupture pressures less than 300 mm Hg were found in 5.7% of cases (8.8% women and 1.2% men). Only 0.6% of patients (1.8% women and 0% men) had a predicted rupture pressure less than 200 mm Hg. No veins with a diameter greater than or equal to 4.0 mm had a predicted patch rupture pressure less than 300 mm Hg. These results suggest that small-diameter saphenous veins have a higher risk of rupture when used as a carotid patch.     

Wall thickness after carotid endarterectomy in patients with paired vein and Dacron patch reconstruction

Purpose: This is an analysis of early postcarotid endarterectomy (CEA) wall thickness in patients who have undergone bilateral operations with vein and Dacron patch reconstructions.Methods: In the past 5 years 23 patients had staged bilateral CEA within 2 months with an autologous greater saphenous vein patch on one side and a knitted Dacron patch on the other. Duplex scans with adequate B-mode resolution to measure common carotid bulb total wall thickness were performed in all 23 patients during the first post-CEA year and in 12 patients in the post-CEA second year.Results: There were no hemodynamically detectable restenoses by Doppler velocity criteria. All peak systolic velocities were ≤110 cm/sec. In the first post-CEA year the total wall thickness of the 23 vein patch CEA was 1.7 ± 1.0 mm (mean ± 1 SD; range, 0.6 to 5.5 mm), and the total wall thickness of the 22 Dacron patch CEA was 1.7 ± 1.1 mm (range, 0.6 to 6.1 mm, p = 0.93). In the second post-CEA year wall thickness was 2.1 ± 1.8 mm (range, 0.6 to 5.8 mm) in the vein patch arteries and 2.0 ± 1.5 mm (range, 0.6 to 5.4 mm, p = 0.91) in the Dacron patch arteries. Although wall thickness of both vein and Dacron patch CEA varied widely between patients, the within-patient absolute difference between the two sides was quite small, 0.1 ± 0.3 mm in the first year and 0.2 ± 0.5 mm in the second. With a 5% chance of a type I statistical error (α = 0.05) to detect a 0.5 mm difference in wall thickness between Dacron and vein patch CEA, the power of the paired t test is >0.999, and the probability of a type II error, β, is <0.001 (power = 1-β) in the first year. In the second year β = 0.34. Wall thickness was bilaterally eccentric in 17 patients. The minimum thickness was in the patch wall, and the maximum was in the opposite endarterectomized wall. It was circumferentially uniform in five patients with <1 mm wall thickness. The single patient with significant bilaterally concentric wall thickness in the first year was the only one who had a marked increase in wall thickness between the first and second years. Wall thickness >2 mm was associated with continued smoking (p = 0.03).Conclusions: Post-CEA wall thickening is highly patient-dependent but is patch material-independent. Knitted Dacron and saphenous vein patch reconstructed carotid arteries develop almost identical wall thickness in a given patient in the first 2 years after endarterectomy. These results support the use of knitted Dacron as an acceptable alternative to greater saphenous for a CEA patch. (J Vasc Surg 1997;25:554-60.)     

Long-term geometric stability of saphenous vein patched carotid endarterectomy

PURPOSE: This study was designed to determine whether there is a generalized trend of progressive enlargement of the common and internal carotid bulbs after carotid endarterectomy (CEA) reconstruction with saphenous vein patches. METHODS: Twenty-nine autologous greater saphenous vein-patched CEAs performed between 1983 and 1994 were examined with five to nine sequential duplex scans each that included B-mode measurements of both the common carotid bulb (CCB) and internal carotid bulb (ICB) diameters. A total of 186 scans of each of the two segments were performed from 2 to 182 months after CEA (mean, 64 months). The time from the first to the last scan ranged from 30 to 120 months (mean, 76 months). Repeated measures analysis of variance was used as a means of testing the relationship of CCB and ICB diameters with time from CEA and with time from the first scan. Simple linear regression was used as a means of analyzing the variability of individual CCB and ICB diameters and pooled normalized diameters in both time frames. RESULTS: The CCB diameters ranged from 8.4 to 18.5 mm (mean, 13.1 mm), and the ICB diameters ranged from 6.4 to 16.0 mm (mean, 11.2 mm). No significant relationship between both CCB and ICB diameters in the time from CEA or the time from the first scan (P =.643 to.913), for sex (P =.403 to.917), or for early and late post-CEA time of study onset (P =.135 to.773) was shown by means of repeated measures analysis. Low R(2) values (CCB mean, 0.17; ICB mean, 0.21) and non-significant P values for regression slope (CCB mean, 0.46; ICB mean, 0.54) were given by means of individual regression analysis. There was no correlation between individual regression coefficients and the mean diameters of the arteries. The mean change in CCB diameter was 0.023 mm/year (range, -0.37 to 0.30 mm/year), and the mean change in ICB diameter was -0.030 mm/year (range, -0.33 to 0.37 mm/year). Regression of normalized CCB and ICB diameters versus time gave R(2) values less than 0.02 and slopes not statistically significantly different from zero. The predicted 10-year average percent change in normalized diameters ranged from 0.8% to 3.3%. CONCLUSION: In a 15-year period after CEA and a 10-year sequential B-mode scan study period, there was no evidence of significant enlargement of saphenous vein-patched CEAs. This is also true for CEAs in men and women and for subsets with larger and smaller CCB and ICB diameters and early and late scan onset times. Dilatation after saphenous vein patching is most likely a rare isolated event and not the result of generalized or frequent progressive enlargement.     

Saphenous vein patch versus primary closure for carotid endarterectomy: Long-term assessment of a randomized prospective study

Purpose: This study examines the long-term results of a randomized prospective study comparing primary versus saphenous vein patch (VP) closure after carotid endarterectomy (CEA).Methods: One-hundred thirty-six patients undergoing 163 CEAs over a 46-month period were prospectively randomized to VP, or primary closure. Patients with internal carotid artery diameters less than 5 mm and those requiring complex CEAs underwent obligatory vein patch (OVP). Patients were monitored with duplex scanning every 3 months for 1 year and every 6 months thereafter. All patients received aspirin.Results: There were three perioperative strokes (one in the primary group, two in the OVP group) and no perioperative deaths. Two perioperative revisions were performed within 30 days of the original CEA for residual disease. During a mean follow-up of 59 ± 4 months, nine ipsilateral neurologic events have occurred, including two strokes and seven transient ischemic attacks. Sixteen patients had duplex evidence of recurrent stenosis, and one was associated with a stroke 36 months after CEA. Recurrence rates were similar in all groups (cumulative recurrence at 5 years: primary 7.8%, VP 14.3%, OVP 5.3%). Of the 136 patients (163 procedures), 72 (53%) (88 procedures) are alive and well, 16 (11.7%) (19 procedures) have been lost to follow-up, and 48 patients (35.3%) (56 procedures) have died. The cumulative stroke-free survival rate at 84 months was 71% for VP, 74% for OVP, and 60% for the primary group.Conclusions: These results demonstrate that CEA is a durable procedure. The use of VP closure did not produce superior long-term results compared with the use of primary closure in this select group of patients.     

Restenosis after carotid endarterectomy in patients with paired vein and Dacron patch reconstruction

This is an analysis of restenosis after bilateral carotid endarterectomy (CEA) with saphenous vein patch reconstruction on one side and Dacron patch reconstruction on the other. The possibility that differences in reconstruction geometry between vein and Dacron patched sides effected restenosis outcomes was evaluated as was the value of serial common carotid wall thickness measurements in predicting restenosis. Between 1990 and 1997, 33 bilateral CEA were performed within one year on 22 men and 11 women using a greater saphenous vein patch on one side and a knitted Dacron patch on the other. Interoperative post-CEA geometry was measured. Follow-up was by duplex scans that included wall thickness measurements in the endarterectomized common carotid bulb. Over a mean follow-up of 43 months 10 (30%) Dacron patched and one (3%) vein patched CEA developed > or = 25% restenosis (p = 0.001), seven (21%) Dacron patched and no vein patched CEA developed > or = 50% restenosis (p = 0.01) and four (12%) Dacron patched and no vein patched CEA developed > or = 70% restenosis (p = 0.11). The Kaplan-Meier cumulative > or = 25% restenosis rates for Dacron and vein patched CEA were 22% and 0% at 2 years and 41% and 5% at 5 years respectively (p = 0.002). The cumulative > or = 50% restenosis rates for Dacron and vein patched CEA were 16% and 0% at 2 years and 34% and 0% at 5 years respectively (p = 0.003). The cumulative > or = 70% restenosis rates for Dacron and vein patched CEA were 8% and 0% at 2 years and 20% and 0% at 5 years respectively (p = 0.02). For both patients with and without recurrent stenosis the mean within patient between sides differences of the diameters of the internal carotid, internal carotid bulb, common carotid bulb, and common carotid arteries and the lengths of the internal carotid and total patch segments were not significantly different and all were less than 5%. Common carotid bulb wall thickness measured at the time of identification of the nine unilateral Dacron patched CEA restenosis was 1.5 +/-0.5 mm compared to 1.4 +/-0.4 mm (m +/-1 SD) for the contralateral vein patched CEA (p = 0.45 by paired t test). Dacron patched CEA have a significantly higher incidence of mild, moderate and severe restenosis than do saphenous vein patched CEA independent of systemic risk factors. The within patient equality of Dacron and vein patched carotid reconstruction geometry in patients with unilateral restenosis indicates that patch material is the major local risk factor, not adverse hemodynamics produced by variance in geometry. Common carotid bulb wall thickness measurements after CEA are not predictors or indicators of recurrent stenosis.     

Vein adaptation to the hemodynamic environment of infrainguinal grafts

Purpose: Although arteries appear to remodel in response to changes in hemodynamic parameters such as shear stress, little is known about functioning human vein grafts. This study was designed to explore diameter changes in human saphenous vein grafts after infrainguinal bypass.Methods: We used duplex ultrasonography to measure hemodynamic variables that might affect the diameter of 48 in situ saphenous vein grafts during the first year after infrainguinal arterial bypass. Volumetric flow rate, average velocity, peak systolic velocity, and vein diameter in the proximal and distal thirds of these grafts were each measured at 1 week and at 3, 6, and 12 months after operation. Veins were divided into three groups based on initial size (1 week after bypass) in the below-knee segment: small, < 3.5 mm diameter; medium, 3.5 to 4 mm diameter; and large, > 4 mm diameter.Results: Distal vein diameters at 1 week for small, medium, and large grafts were 2.9 ± 0.1, 3.7 ± 0.1, and 4.3 ± 0.1 mm, respectively (p < 0.001), but by 12 months these diameters were 3.6 ± 0.2, 3.8 ± 0.2, and 3.9 ± 0.2 mm, respectively (p = 0.54). Large veins decreased in diameter, whereas small veins increased in diameter, as confirmed by linear regression of percent change in diameter versus initial vein graft diameter (r = -0.62, p < 0.001). Volumetric flow rate, peak systolic velocity, and shear stress also tended to approach uniform values over time. Of the hemodynamic variables studied, the best predictor of diameter change was shear stress (linear regression of percent change in diameter vs shear stress, r = 0.67, p < 0.001). Veins with a diameter increase greater than 10% over time had significantly higher initial shear stress than veins with a diameter decrease greater than 10% over time (28.6 ± 3.8 vs 13.1 ± 1.8 dynes/cm², p < 0.01), whereas initial volumetric flow rates in these two groups were similar (135 ± 23 vs 130 ± 15 ml/min).Conclusions: Infrainguinal in situ vein graft diameter, volume flow rate, peak systolic velocity, and shear stress all tend to stabilize at uniform values regardless of the initial vein graft diameter. Of the hemodynamic variables studied, shear stress is most strongly associated with the change in diameter over time. Thus human saphenous vein appears to be capable of adapting to its hemodynamic environment after arterial grafting by modulating diameter to normalize shear stress. (J VASC SURG 1994;19:970–9.)     

Is there carotid artery aneurysm formation following saphenous vein patch endarterectomy?

The use of saphenous vein patching following carotid endarterectomy is reported to produce aneurysmal dilatation with the risk of thrombosis and possible rupture. The authors have studied patients who have had saphenous vein patch angioplasty following carotid endarterectomy to assess whether there is any progressive arterial dilatation. Thirty-five patients who had undergone saphenous vein patch carotid endarterectomy were age- and sex-matched with 31 subjects that had direct closure endarterectomy. All participants underwent carotid duplex scanning. The external diameters of the mid common carotid artery, the bulb and the proximal internal carotid artery were measured bilaterally. The diameters of the endarterectomized carotid were compared with the contralateral side using a paired t-test. Using an unpaired t-test, the saphenous vein angioplasty group was compared with the directly closed group. A graph was plotted of the ratio of internal carotid artery diameter of the saphenous vein angioplasty group (endarterectomized artery to the contralateral artery) against the length of follow-up, and the Pearson correlation coefficient was calculated. When the saphenous vein angioplasty group was compared with the directly closed group there was a significant difference between the carotid bulb (11.6 versus 9.7mm, P < 0.001) and internal carotid artery diameters (9.0 versus 7.0mm, P < 0.001). Longitudinal analysis of the saphenous vein angioplasty group showed that the increased diameter of the endarterectomized internal carotid artery progressed with time after surgery (r = 0.51, P < 0.005, and r = 0.56, P < 0.001). Vein patching increases the diameter of the internal carotid artery, and this may further increase with time possibly predisposing to aneurysm formation. Further longitudinal studies of paired data are required.     

Saphenous vein patch rupture after carotid endarterectomy.

From January 1983 to September 1990, 2731 carotid endarterectomies were performed at The Cleveland Clinic. Patch angioplasty with autogenous saphenous vein was used for arteriotomy closure during 1691 (62%) of these procedures and was associated with eight postoperative ruptures (0.5%) of the central portion of the patch in seven patients. This complication occurred in three men and in four women (mean age, 69 years), all of whom were hypertensive and all but one were smokers. Two patients (29%) had diabetes. In each case of patch rupture the vein had been harvested from the leg distal to the knee. Although the harvest site could not be determined retrospectively for every patient in this series, no patch ruptures were encountered among 370 procedures for which it could be documented that the saphenous veins had been obtained from the groin. All ruptures occurred within 5 days of the primary operations (including four during the first 24 hours) and were urgently corrected by primary closure of the original arteriotomy in two cases and by replacement of the ruptured patch in the remaining six. Two (29%) of the seven patients either died or sustained a permanent neurologic deficit. Central rupture of a saphenous vein patch is a rare but devastating complication after carotid endarterectomy. Since vein harvested from the lower leg or ankle may be marginally more likely to rupture than proximal vein from the thigh or groin, it should not be used indiscriminately for carotid patch angioplasty.     

Incompetent Great Saphenous Veins Treated with Endovenous 1,320-nm Laser: Results for 71 Legs and Morphologic Evolvement Study

BACKGROUND: Endovenous lasers with various wavelengths have been utilized with good outcomes in treating leg varicose veins. The natural history and evolution of treated veins after endovenous procedures, however, have seldom been addressed. OBJECTIVE: This study determines the efficacy vein ablation and serial venous morphologic evolution of incompetent great saphenous veins (GSVs) after endovenous 1,320-nm laser treatment. METHODS: Fifty patients with symptomatic varicose veins secondary to GSV insufficiency treated with 1,320-nm endovenous laser ablation were enrolled. The treated varicose veins in each limb were mapped and sized before laser treatment. Vein wall diameters were measured with duplex ultrasound at follow-up visits. RESULTS: Seventy-one limbs in 50 patients were enrolled. During the mean 13.1-month follow-up, closure of GSVs was observed in 94% of limbs (67/71). Vein diameters at 3 cm below saphenofemoral junction level were reduced to 81% at 2 days, 75% at 1 month, 48% at 3 months, and 39% at 5 months. Average mean duration for treated GSVs to narrow as fibrotic cords (internal diameter,<2.5 mm) was 5.8 months. CONCLUSION: The endovenous 1,320-nm laser ablation procedures have excellent efficacy in treating incompetent GSVs. This excellent shrinkage behavior may be the basis for nice long-term results of patients treated with 1,320-nm Cooltouch endovenous laser.     

Use of the internal jugular vein for carotid patch angioplasty

The internal jugular vein is an excellent source of autogenous tissue for carotid artery reconstruction because of its availability in the operative incision, adequate size, and ability to be harvested without morbidity. For 153 of 453 consecutive carotid reconstructions, the durability of the internal jugular vein (n = 76) and the greater saphenous vein (n = 77) as a patch angioplasty was compared. Mean postoperative follow-up was 17 months (1 to 52 months). The vein-patched carotid-bifurcation was studied by means of duplex ultrasonography to assess patency, detect restenosis, and measure cross-sectional diameter during systole. No carotid bifurcation occluded after operation. No ruptures or aneurysmal dilatations of the vein patches were observed. The maximum diameter (mean +/- SD) of the carotid patch angioplasties constructed with internal jugular vein (9.4 +/- 1.9 mm) was similar to patches made with greater saphenous vein (9.6 +/- 1.7 mm). In 95 patients serial duplex examinations demonstrated maximum diameter changes of the vein-patched internal carotid artery ranging from an increase of 3.5 mm to a decrease of 3.0 mm. Asymptomatic restenosis (greater than 50% diameter reduction) was detected in 2/95 (2.1%) patients. Because of the premium placed on the saphenous vein for peripheral arterial reconstruction and coronary artery bypass grafting, the ipsilateral internal jugular vein should be used more frequently for carotid patch angioplasty.     

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.)     

Correlation between preoperative and postoperative duplex vein measurements of the greater saphenous vein used for infrainguinal arterial reconstruction

Vein diameter measurements using B-mode Doppler ultrasound (US) are used to assess the greater saphenous vein (GSV) for bypass operations; a 2.5-3.0 mm diameter is suggested as a minimum. Preoperative measurements are made while the vein is in the low-pressure venous system. This may not reflect the distended diameter of a vein after placement in the arterial system. This study compares preoperative and postoperative GSV diameters to identify the degree of dilatation and the minimal size adequate for use in arterial bypass operations. The GSV of 11 patients undergoing an infrainguinal arterial bypass were assessed by utilizing Doppler US. Measurements were taken every 10 cm, for 70 cm, along the course of the GSV before and 4 weeks after operation. All segments showed a percent increase in diameter from the preoperative to postoperative time points; 10 cm, 38+/-; 20 cm, 31+/-; 30 cm, 16+/-; 40 cm, 26+/-; 50 cm, 23+/-; 60 cm, 28+/-; and 70 cm, 22+/-. A Bonferroni post hoc analysis between the 2 time point means showed a significant increase in means for the 2 time points of 9.49 units (Bonf p value < 0.001). Preoperative vein segments were divided into 3 categories: 4.1 mm. All showed a significant increase over time. Preoperative diameter measurements of the vein may not reflect the final distended diameter after bypass. Preoperative vein diameters 相似文献   

Venous patch grafts and carotid endarterectomy. A critical appraisal

Seventy-eight patients underwent 83 carotid endarterectomies (CEAs) with vein patch grafts from 1980 to 1985. A technically satisfactory endarterectomy was confirmed by completion arteriogram in all instances. Indications for venous patch graft included a diameter of the internal carotid artery of less than 3.0 mm (49 patients); an internal carotid artery diameter of less than 3.5 mm, with contralateral internal carotid artery occlusion (nine patients); unexpected stenosis detected by completion arteriogram (six patients); a reexploration for neurologic deficit following conventional CEA (three patients); and irregular surface or edges of the endarterectomy site or high extension of a plaque (16 patients). Late follow-up arteriograms (66 studies) after a mean two-year interval revealed three instances (4.5%) of recurrent asymptomatic stenosis. Four patients (6%) developed late occlusions; three were asymptomatic and one was associated with major stroke 2 1/2 years later. One patient (1.5%) developed a false aneurysm. One patient experienced a postoperative transient ischemic attack. There was no operative mortality. Six patients died in the late follow-up period. The venous patch graft ensured immediate patency of the internal carotid artery but failed to prevent recurrent stenosis or occlusion in internal carotid arteries less than 3.0 mm in diameter.     

Prospective randomized trial of carotid endarterectomy with primary closure and patch angioplasty with saphenous vein,jugular vein,and polytetrafluoroethylene: Long-term follow-up

Purpose: This study examines the long-term clinical outcome and the incidence of recurrent stenosis (≥50%) after carotid endarterectomy (CEA) with primary closure (PC) versus vein patch closure (VPC), saphenous (SVP), and jugular vein (JVP) and polytetrafluoroethylene patch closure (PTFE-P). Methods: A total of 399 CEAs were randomized into the following groups: 135 PC, 134 PTFE-P, and 130 VPC (SVP alternating with JVP). Postoperative duplex ultrasound scans were performed at 1, 6, and 12 months and every year thereafter. The mean follow-up was 30 months with a range of 1 to 62 months, and demographic characteristics were similar in all groups. Kaplan-Meier analysis was used to estimate the risk of restenosis and the stroke-free survival. Results: The incidence of ipsilateral stroke was 5% (seven of 135) for PC, 1% (one of 134) for PTFE-P, and 0% for VPC (PC vs VPC, p = 0.008; PC vs PTFE-P, p = 0.034). Seven strokes occurred in the perioperative period. All three groups had similar mortality rates. The cumulative stroke-free survival rate at 48 months was 82% for PC, 84% for PTFE-P, and 88% for VPC (p < 0.01 for PC vs PTFE-P or VPC). PC had a higher incidence of recurrent stenosis and occlusion (34%) than PTFE-P (2%) and VPC (9%) (SVP 9%, JVP 8%) (p < 0.001). PTFE-P had a lower recurrent stenosis rate than VPC (p < 0.045). Restenoses necessitating a redo CEA were also higher for PC (11%) than for PTFE-P (1%) and VPC (2%) (p < 0.001). Women with PC had a higher recurrent stenosis rate than men (46% vs 23%, p = 0.008). Kaplan-Meier analysis showed that freedom from recurrent stenosis at 48 months was 47% for PC, 84% for VPC, and 96% for PTFE-P (p < 0.001). The SVP and JVP results were comparable. The mean operative diameter of the internal carotid artery was similar in patients with or without restenosis. Significantly more late internal carotid artery dilatations occurred in the VPC group compared with the PC group. Conclusions: Patch closure (VPC or PTFE-P) is less likely than PC to cause perioperative stroke. Patching was also superior in lowering the incidence of late recurrent stenoses, especially in women. (J Vasc Surg 1998;27:222-34.)     

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.     

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.     

Pregnancy-induced changes in lower extremity superficial veins: an ultrasound scan study

OBJECTIVE: The purpose of this study was to follow changes in superficial veins of the lower extremities during pregnancy and the postpartum period in women with varicose veins. METHODS: This was a prospective study with the use of duplex scanning during the first and third trimesters of pregnancy and postpartum period. Competent veins were defined as veins with an absence of reflux, and incompetent veins were defined as veins with reflux. The diameter of the competent or incompetent greater saphenous vein (GSV) and lesser saphenous vein (LSV) was measured. The diameter of the largest varicose dilatations was measured in all three networks: GSV and its tributaries, LSV and its tributaries, and nonsaphenous varicose veins. RESULTS: Sixty-six women were studied prospectively (mean age, 32.2 +/- 4 years; 85 affected extremities). The diameter of competent and incompetent GSVs and competent LSVs increased between the first and third trimester (P <.001) and decreased between the third trimester and the postpartum period (P <.001). The diameter of the largest varicose dilatations of the GSV and its tributaries and nonsaphenous networks increased between the first and third trimester (P <.001) and decreased between the third trimester and the postpartum period (P <.001). No statistically significant variation of the diameter was demonstrated for any of these veins between the first trimester and the postpartum period. CONCLUSION: The diameters of competent and incompetent superficial veins increased during pregnancy and decreased during the postpartum period to return to their baseline values.     

Recurrent carotid artery stenosis. Resection with autogenous vein replacement.

Recurrent carotid artery stenosis (RCAS) occurs in 10% to 15% of patients following carotid endarterectomy (CEA). A recurrent stenosis may occur as early as 6 months and will become symptomatic in 3% to 5% of patients. Early stenosis is myointimal hyperplasia, but with the passage of time may progress to the characteristic atherosclerotic lesion. Improvements in noninvasive testing allows for evaluation and early detection of restenosis. Since 1974 we have performed 3711 CEAs in 2909 patients. One hundred and six second or third CEAs were performed in 98 patients (3.5%). In 20 of these reoperations, the common carotid (CCA) and internal carotid artery (ICA) were resected and replaced by autogenous vein, usually saphenous. One of these patients had 3 previous CEAs while 7 patients had 2 and 12 patients had 1 previous operation. There were no deaths; thrombosis of one vein interposition requiring replacement occurred. Hoarseness and hypoglossal nerve palsy occurred in one patient. Follow-up ranged to 5 years with a mean of 2.8 years. Although a second CEA is possible, there are inherent technical difficulties that may be encountered and vein interposition will solve these as well as offer the potential to prevent a further recurrence.     

Risk factors associated with recanalization of incompetent saphenous veins treated with radiofrequency ablation catheter

Purpose

The purpose of this study was to determine the occlusion rate of incompetent great saphenous veins (GSVs) and small saphenous veins (SSVs) treated with radiofrequency ablation (RFA) and individualize variables associated with recanalization.

Carotid endarterectomy outcome with vein or Dacron graft patch angioplasty and internal carotid artery shortening

OBJECTIVE: This analysis of the outcome of carotid endarterectomy (CEA) was performed during a period of transition from the frequent use of autologous greater saphenous vein grafting to the frequent use of Dacron graft patch reconstruction and from the infrequent use to the moderate use of eversion plication shortening of the endarterectomized internal carotid artery segment. METHODS: From 1990 to 1997, 697 consecutive primary CEAs were performed on 326 men (61 bilateral CEAs) and 272 women (38 bilateral CEAs) with a mean age (+/- SD) of 68 +/- 9 years. The indications were transient ischemic attack in 31% of the patients, stroke or reversible ischemic neurologic deficit in 18%, global ischemia in 12%, and asymptomatic stenosis >/=70% in 39%. Patch reconstruction was performed in the 678 CEAs in which the arteriotomy extended distal to the internal carotid artery bulb (97%; 370 saphenous vein grafts, 308 Dacron grafts). Primary closure was used in the other 19 CEAs. Early in this series, saphenous vein patching frequently was performed, with a gradual transition to the frequent use of knitted Dacron grafts. Concurrent with this, the frequency of the shortening of the internal carotid artery increased from 7% to 40%. Postoperative duplex scans were obtained on 619 CEAs (91%). RESULTS: There were four deaths (0.6%) in 30 days-three from myocardial infarction and one from hyperperfusion stroke. Thirteen strokes (1.9%), nine ipsilateral and four contralateral, occurred in 30 days. Four nonfatal strokes and one death occurred in the saphenous vein group (3.2%), and eight strokes and two deaths occurred in the Dacron graft group (1.4%; P =.16). The combined 30-day stroke or death rate was 2.3% (16/697), and the hospital rate was 1.7% (12/697). Of the three internal carotid artery occlusions, two were identified at 2 months (one Dacron graft, one saphenous vein) and one was identified at 1 year (Dacron graft). Nonocclusive (>/=50%) restenosis was identified in 16 CEAs. Fifteen of these were in the internal carotid artery. The cumulative Kaplan-Meier method of life-table analysis for the >/=50% restenosis rate at 2 months, 6 months, 1 year, and 3 years for Dacron graft patched CEA was 1.7%, 2.3%, 8.8%, and 12.3% and for saphenous vein patched CEA was 0.3%, 0.3%, 0.3%, and 1.1% ( P <.0001). At the same time intervals, the >/=50% restenosis rate for internal carotid artery shortening was 1.0%, 2.5%, 13.7%, and 19.5%, and, when shortening was not done, the rate was 0.8%, 0.8%, 1.1%, and 3.1% (P <.0001). The >/=50% restenosis rate at the same intervals for women was 0.8%, 1.3%, 5.2%, and 8.9%, and, for men, the rate was 0.9%, 0.9%, 1.8%, and 2.5% (P =.11). Univariate analysis of the rate of >/=50% restenosis in 3 years for the 346 vein patched (2; 0.6%) and 186 Dacron graft patched (7; 3.8%) CEAs that did not have internal carotid artery shortening gave a P value of .015. Similarly, Kaplan-Meier method analysis of this subset of nonshortened CEAs gave a higher restenosis rate with Dacron graft patching (P =.012). With multiple logistic regression, the >/=50% restenosis rate was significantly associated with Dacron graft patching (P =.023; odds ratio, 4.5) and internal carotid artery shortening (P =.025; odds ratio, 3.1) and was weakly associated with female gender (P =.15; odds ratio, 2.0). Cox proportional hazards model analysis for >/=50% restenosis gave relative risk ratios of 3.0 (1.6 to 6.8; 95% confidence interval [CI]) for Dacron graft versus vein patching, 2.0 (1.2 to 3.3; 95% CI) for shortening versus not shortening, and 1.5 (0.9 to 2.4; 95% CI) for female versus male gender. CONCLUSION: CEA patching with Dacron grafts and saphenous vein grafts have similar low perioperative thrombosis, stroke, and death rates, although the stroke and death rates were slightly higher but not statistically different when Dacron grafts were used. Dacron graft patched CEAs are more likely to develop >/=50% restenosis than are those that are patched