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.     

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.     

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.     

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.     

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.     

Patterns of saphenous reflux in women with primary varicose veins

OBJECTIVE: Varicose veins have been linked to great saphenous vein (GSV) reflux and in particular, with reflux at the saphenofemoral junction (SFJ). Early stages of disease, however, may be associated with limited, localized reflux in segments of the GSV and/or small saphenous vein (SSV). Ultrasound mapping of saphenous veins was performed to determine patterns of GSV and SSV reflux in women with simple, primary varicose veins. METHODS: Ultrasound mapping was performed prospectively in 590 extremities of 326 women with varicose veins (CEAP C 2 class) but without edema, skin changes, or ulcers (C 3 to C 6 ). Average age was 42 +/- 13 (SD) years (range, 8 to 87). Patterns of GSV and SSV reflux, obtained in the upright position, were classified as I: perijunctional, originating from the SFJ or saphenopopliteal junction (SPJ) tributaries into the GSV or SSV; II: proximal, from the SFJ or SPJ to a tributary or perforating vein above the level of the malleoli; III: distal, from a tributary or perforating vein to the paramalleolar GSV or SSV; IV: segmental, from a tributary or perforating vein to another tributary or perforating vein above the malleoli; V; multisegmental, if two or more distinct refluxing segments were detected; and VI: diffused, involving the entire GSV or SSV from the SFJ or SPJ to the malleoli. RESULTS: Reflux was detected in 472 extremities (80%): 100 (17%) had reflux in both the GSV and SSV, 353 (60%) had GSV reflux only, and 19 (3%) had SSV reflux only, for a total prevalence of 77% at the GSV and 20% at the SSV. The most common pattern of GSV reflux was segmental (types IV and V) in 342 (58%) of 590; either one segment in 213 (36%) or more than one segment with competent SFJ in 99 (17%), or incompetent SFJ in 30 (5%), followed by distal GSV reflux (type III) in 65 (11%), proximal GSV reflux (type II) in 32 (5%), diffused throughout the entire GSV (type VI) in 10 (2%), and perijunctional (type I) in 4 (<1%). GSV refluxing segments were noted in the SFJ in 72 (12%) and in the thigh in 220 (37%), and leg (or both) in 345 (58%). CONCLUSIONS: The high prevalence of reflux justifies ultrasound mapping of the saphenous veins in women with primary varicose veins. Correction of SFJ reflux, however, may be needed in 相似文献   

Measurement of distance between femoral insertion of fibular collateral ligament and popliteus tendon: A magnetic resonance imaging based study

BackgroundFibular collateral ligament (FCL), popliteus tendon (PT) and popliteofibular ligament are key components of posterolateral corner (PLC) of the knee. These structures play a vital role in stabilizing the knee against varus and external rotation. The Anatomical location of these structures should be well understood for adequate reconstruction of PLC injuries.Purpose of our study is to measure mean distance between femoral insertion of FCL and PT; femoral medio-lateral dimension (MLD) and antero-posterior dimension (APD) of lateral femoral condyle on Magnetic Resonance Imaging (MRI) images and its relevance to anatomical reconstruction of PLC injuries of knee.MethodsThe knee MRI data of 68 patients (43 males and 25 females) were studied. Measurement of PT-FCL distance was done in sagittal proton density fat-saturated (PDFS) sequence images. The femoral MLD and APD were measured in axial PDFS sequence images. The mean of each parameter was calculated and analyzed. To identify inter-observer agreement, we calculated Intra-Class Correlation Coefficient (ICC) for each parameter.ResultsThe mean PT-FCL distance was 16.85 ± 1.55 mm (range 12.9–21.2 mm). In our observation, PT always inserts anteriorly and distally to FCL insertion on the lateral femoral condyle. The mean MLD was 78.74 ± 5.84 mm (range 65–90 mm). The Mean APD of the lateral femoral condyle was 60.47 ± 4.00 mm (range 52.5–69.5 mm). The difference between the mean values of all the above parameters in both genders was statistically significant (p-value <0.05). Inter-observer agreement was very good for measurement of PT-FCL distance (ICC 0.96), MLD (ICC 0.98) and APD (ICC 0.97).ConclusionThe mean distance between femoral insertion of FCL and PT in our study was less in comparison to most of the western literature. However, despite this anatomical variation, the method of PLC reconstruction proposed in western literature can be safely advocated in the Indian population as well.     

Hybrid screw fixation for femoral neck fractures: Does it prevent mechanical failure?

IntroductionTraditionally, femoral neck fracture fixation has been performed using three partially threaded cancellous screws. However, fracture collapse with femoral neck shortening, and varus deformation frequently occurs due to posterior medial comminution and lack of calcar support. We hypothesize replacing the inferior neck/calcar screw with a fully threaded, length stable, screw will provide improved biomechanical stability, decrease femoral neck shortening and varus collapse.MethodsTen matched cadaveric pairs (20 femurs) were randomly assigned to two screw fixation groups. Group 1 (Hybrid) utilized one fully threaded calcar screw & two partially threaded superior screws. Group 2 (PT) utilized all partially threaded screws. Specimens underwent standardized femoral neck osteotomies, 45° from the horizontal, with 5 mm posteromedial wedge removed to simulate posteromedial comminution. Screws were placed using fluoroscopic guidance. Specimens were biomechanically tested using two loading sequences: 1) Axial load applied up to 700 N, followed by cyclic loading at 2 Hz with loads of 700 to 1,400 N for 10,000 cycles. 2) All surviving constructs were cyclically loaded to failure in stepwise incremental manner with max load of 4,000 N. Paired t-tests used to compare stiffness, cycles to failure, and max load to failure (defined as 15 mm load actuator displacement).ResultsConstruct stiffness was 2848 ± 344 N/mm in PT vs. 2767 ± 665 for Hybrid (P = 0.628). Load to failure demonstrated, hybrid superiority with max cycles to failure (3797 ± 400 cycles) vs. (2981 ± 856 cycles in PT) (p = 0.010), and max load prior to failure (3290 ± 196 N) vs. (2891 ± 421 N in PT) (p = 0.010). No significant difference in bone mineral density was noted in any of the specimens.ConclusionsOur study is the first to assess the biomechanical effects of hybrid fixation for femoral neck fractures. Hybrid screw configuration resulted in significantly stronger constructs, with higher axial load and increased cycles prior to failure. The advantageous mechanical properties demonstrated using a fully threaded inferior calcar screw provides a length stable construct which may prevent the common complication of excessive femoral neck shortening, varus collapse and poor functional outcome.     

Ultrasound findings after radiofrequency ablation of the great saphenous vein: descriptive analysis

OBJECTIVE: As an emerging endovascular alternative to ligation and stripping of the incompetent greater saphenous vein (GSV), radiofrequency ablation was monitored with ultrasound scanning to evaluate anatomic results. Neovascularization and inflammation are potential consequences that lead to the appearance of small vessels. The natural history of the below-knee untreated GSV segment may be important in our understanding of ongoing chronic venous disease. An ultrasound follow-up study was conducted to determine the prevalence of small vessel networks, defined as veins and arteries less than 2 mm in diameter, adjacent to the saphenofemoral junction (SFJ); prevalence of small vessel networks adjacent to the treated GSV in the thigh; and fate of the below-knee untreated GSV distal to the ablated segment. METHODS: One hundred six extremities with radiofrequency ablation of the GSV for treatment of superficial venous insufficiency were followed up with high-resolution ultrasound imaging 4 to 25 months (median, 9 months) after the procedure. Ninety-three limbs had concomitant ligation and division of the SFJ and its tributaries, and 13 limbs underwent radiofrequency ablation without SFJ ligation. Ultrasound was used to evaluate patients for small vessel networks, and concomitant findings of small vessel networks and recanalization at the SFJ and adjacent to the treated GSV. The status of the below-knee segment of untreated GSV was evaluated for patency and reflux. Data analysis compared the findings in the ligation group with those in the no-ligation group, with the chi 2 test and Fisher exact test. RESULTS: We found small vessel networks in 65% (n = 69) of extremities: 15% (n = 16) at the SFJ only, 26% (n = 28) in the thigh only, and 24% (n = 25) at both the SFJ and thigh, resulting in a small vessel network prevalence of 39% (n = 41) at the SJF and 50% (n = 53) in the thigh. The prevalence of small vessel networks at the SFJ was significantly less after radiofrequency ablation with SFJ ligation (34%, 32 of 93) than after radiofrequency ablation without ligation (69%, 9 of 13; P = .035). Small vessel networks and GSV recanalization at the SFJ was more common in patients undergoing radiofrequency ablation without ligation (46%, 6 of 13) than after radiofrequency ablation with ligation (14%, 13 of 93; P = .014). The prevalence of small vessel networks in the thigh was not affected by SFJ ligation. The below-knee GSV was patent in 79% (84 of 106), and 58% (61 of 106) demonstrated reflux, a decrease from the pre-radiofrequency ablation rate of 71% (75 of 106), possibly because thrombosis extended distally beyond the ablated segment in 16% (17 of 106) of the legs. CONCLUSIONS: Small vessel networks were detected adjacent to or in connection with most of the radiofrequency ablation-treated GSVs. SFJ ligation was associated with fewer small vessel networks and proximal GSV recanalization. Most below-knee untreated GSV segments remained patent, and most exhibited reflux.     

Sapheno-femoral Junction Reflux in Patients with a Normal Saphenous Trunk

OBJECTIVE: To determine the patterns and clinical importance of saphenofemoral junction (SFJ) reflux in patients with chronic venous disease (CVD) and a normal great saphenous vein (GSV) trunk. METHODS: Fifteen hundred consecutive patients were examined using duplex ultrasound (DU) in three centres. Patients with reflux involving the SFJ and/or its tributaries only were included and its prevalence and patterns were studied. Patients with GSV trunk reflux or in any other veins were excluded. The SFJ diameter was categorised as normal, dilated or varicose. The results of surgery were evaluated by DU in 42 patients 1 year after the procedure. RESULTS: SFJ area incompetence with a competent GSV trunk occurred in 8.8% of limbs. It was significantly more common in CEAP class 2, 13.6% compared to class 3, 8.2% (p=0.03), class 1, 2.7%, class 4, 4.4% and classes 5 and 6 together, 1.5% (p<0.001 for all). The SFJ had a normal diameter in 21%, dilated in 62% and varicose in 17%. Reflux was seen in 39% of limbs with a normal SFJ diameter, in 85% of those with a dilated SFJ and in all varicose SFJs. Of the 42 operated limbs, 27 had ligation and division of the SFJ and tributary phlebectomies. Fifteen had tributary phlebectomies only, leaving the SFJ intact. At one-year follow-up, SFJ area reflux was found in six limbs (14.3%), involving the SFJ alone in 1, a main tributary in 1 and 4 small tributaries. No reflux was found in the GSV trunk. All but two of the 42 patients were satisfied with the results. CONCLUSIONS: SFJ reflux with tributary involvement and sparing of the GSV trunk occurs in 8.8% of CVD patients. Such reflux is found in the entire spectrum of CVD, but it is more common in class 2. Local surgery with or without SFJ ligation has very good results at 1 year. DU scanning prior to treatment is important in all patients so that the intact GSV can be spared.     

Durability of reflux-elimination by a minimal invasive CHIVA procedure on patients with varicose veins. A 3-year prospective case study.

OBJECTIVES: to assess the outcome of a conservative and haemodynamic method for insufficient veins on an ambulatory basis (French acronym, "CHIVA") with preservation of the greater saphenous vein (GSV) for treatment of primary varicose veins. METHODS: duplex incompetence of the sapheno-femoral junction (SFJ) and the GSV trunk, with the re-entry perforating point located on a GSV tributary was demonstrated in 58 patients with varices (58 limbs). The re-entry point was defined as the perforator, whose compression of the superficial vein above its opening eliminates reflux in the GSV. Duplex scanning was performed preoperatively and at 7 days, and patients were followed prospectively at 1, 3, 6, 12, 24, and 36 months after CHIVA. Operation consisted in flush ligation and division from the GSV of the tributary containing the re-entry perforating vein (no additional high ligation is included). If reflux returned, SFJ interruption was performed in a second surgical procedure. RESULTS: the GSV diameter showed an average reduction from 6.6 to 3.9 mm 36 months after surgery. Reflux in the GSV system was demonstrated in all but five (8%) patients. Of the 53 patients with recurrent reflux, 46 underwent SFJ interruption. CONCLUSIONS: elimination of reflux in the GSV after the interruption of insufficient collaterals is only temporary.     

Comparison of manual compression release with distal pneumatic cuff maneuver in the ultrasonic evaluation of superficial venous insufficiency.

BACKGROUND: Venous reflux can be elicited either manually or by pneumatic tourniquet, and previous studies did not indicate any significant difference between these manoeuvres in patients with superficial venous insufficiency (SVI). PURPOSE: To investigate if two methods correlate in patients with CVI. MATERIALS AND METHODS: Venous reflux was studied in 94 venous segments of 57 limbs in 52 consecutive patients with SVI. Limbs were divided into two groups: group I (CEAP C2-C3) and group II (CEAP C4-C6). A colour duplex scanner was used to determine quantitative venous reflux at the sapheno-femoral junction (SFJ), at the sapheno-popliteal junction (SPJ), and in the greater saphenous vein in the thigh (GSV). Patients received both manual compression and cuff deflation method in eliciting venous reflux. The parameters assessed were the duration of reflux (second) and the peak reflux velocity (cm/s). STATISTICS: Paired t-test was used to evaluate differences between the two methods. Statistical significance was recorded when the p-value was <0.05. Bland and Altman plot was also used to assess the agreement of the same measurement. RESULTS: There were 58 venous segments in group I and 36 in group II. In group I, there were no significant differences in the duration of reflux at the SFJ, SPJ, and in the GSV. On the contrary, peak reflux velocity was found to be significantly higher at the SFJ and in the GSV (p=0.022 and 0.006, respectively). In group II, there was no significant difference in the duration of reflux at the SFJ and SPJ between the two methods. On the contrary, manual compression maneuver produced significantly higher peak reflux velocity than at the SFJ and in the GSV (p=0.023 and 0.002, respectively). Bland and Altman plot analysis, manual compression method displayed a relatively good agreement with cuff deflation manoeuvre both in group I and group II. In contrast, concerning the peak reflux velocity, relative wide limits of agreement were found between the two methods. CONCLUSIONS: Unlike previously published reports, our results lead to apparent discrepancies in the quantitative evaluation of venous reflux using different methodology.     

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.     

Management and results of thyroidectomies in pediatric patients with MEN 2 syndrome

Aim of the studyTo evaluate the outcome of prophylactic thyroidectomies (PT) in patients with MEN 2 syndrome in a tertiary center.MethodsA retrospective study was designed, including all patients with MEN 2 syndrome who underwent PT between 2000 and 2019. Demographics, gene mutation, postoperative complications and histopathological findings were registered.Main results30 patients were included (29 MEN 2A and 1 MEN 2B) with a median age at surgery time of 7.0 ± 3.2 years. Familiar history was present in all but 3 patients. A therapeutic thyroidectomy was performed in 2 patients due to evidence of medullary thyroid carcinoma (MTC, both were late diagnosis), and in the other 28 cases, a PT was performed. 8 patients had a RET mutation ranked as Moderate Risk (American Thyroid Association): median age at surgery was 7.2 ± 4.2 years, and histological findings were C-cell hyperplasia (n = 6) and no alterations (n = 2). 16 patients had a high risk mutation; median age at surgery time was 6.9 ± 2.8 years and histological findings were normal thyroid gland (n = 1), C Cell Hyperplasia (n = 8), microcarcinoma (n = 6), and MTC (n = 1). The mean hospital stay was 1.4 ± 0.68 days. No intraoperative complications or recurrent laryngeal nerve injuries were registered. 7 patients presented a transient hypoparathyroidism and 1 patient had permanent hypoparathyroidism.ConclusionsEarly PT in patients with MEN 2 syndrome is a safe procedure when performed by an experienced team of Pediatric Surgeons and with a multidisciplinary approach. Early genetic analysis and familial counselling is essential to prevent the development of a MTC.     

Defining the role of extended saphenofemoral junction ligation: a prospective comparative study

OBJECTIVE: This study explores the added effect of extended saphenofemoral junction (SFJ) ligation when the greater saphenous vein (GSV) has been eliminated from participating in thigh reflux by means of endovenous obliteration. GSV obliteration, unlike surgical stripping, can be done with or without SFJ ligation to isolate and study SFJ ligation's specific contribution to treatment results. METHODS: Sixty limbs treated with SFJ ligation and 120 limbs treated without high ligation were selected from an ongoing, multicenter, endovenous obliteration trial on the basis of their having primary varicose veins, GSV reflux, and early treatment dates. RESULTS: Five (8%) high-ligation limbs and seven (6%) limbs without high ligation with patent veins at 6 weeks or less were excluded as unsuccessful obliterations. Treatment significantly reduced symptoms and CEAP clinical class in both groups (P =.0001). Recurrent reflux developed in one (2%) of 49 high-ligation limbs and eight (8%) of 97 limbs without high ligation by 6 months (P =.273). New instances of reflux did not appear thereafter in 57 limbs followed to 12 months. Recurrent varicose veins occurred in three high-ligation limbs and four limbs without high ligation by 6 months and in one additional high-ligation limb and two additional limbs without high ligation by 12 months. Actuarial recurrence curves were not statistically different with or without SFJ ligation (P >.156), predicting greater than 90% freedom from recurrent reflux and varicosities at 1 year for both groups. CONCLUSION: These early results suggest that extended SFJ ligation may add little to effective GSV obliteration, but our findings are not sufficiently robust to warrant abandonment of SFJ ligation as currently practiced in the management of primary varicose veins associated with GSV vein reflux.     

Novel values in the radiographic diagnosis of ligamentous Lisfranc injuries

BackgroundLigamentous Lisfranc instability is commonly missed on unilateral radiographs. However, measurement protocols for bilateral weightbearing radiographs have not been standardized. The primary aim of this study was to investigate the optimal cut-off values for diagnosing Lisfranc instability by evaluating the side-to-side differences of preoperative bilateral weightbearing radiographs among patients with surgically-confirmed ligamentous Lisfranc instability. A secondary aim was to investigate whether the midfoot measurements for detecting Lisfranc injury could also be used in patients with a pre-existing bilateral Hallux Valgus (HV) deformity by evaluating whether the Lisfranc measurements could be affected by a foot deformity as HV.Patients and methodsPatients who underwent surgical repair of ligamentous Lisfranc instability, as well as a separate cohort with bilateral hallux valgus deformity, were included in this multicenter retrospective cohort study. A standardized radiographic measurement protocol was used to assess the midfoot and a receiver operator correlation (ROC) analysis was used to identify the optimal cut-off value for measurements. Interclass Correlation (ICC) scores were calculated to assess the interrater reliability of the Lisfranc area measurement.ResultsForty-seven patients were included in the Lisfranc group with a mean age of 33 (± 15) years and 25 patients were included in the HV group with a mean age of 51 (± 15) years. For the Lisfranc group, measurements that demonstrated a significant side-to-side difference included; increased C1M2 diastasis of 2.4 mm (± 1.4, P<0.001), increased C1M2 surface area of 24 mm² (± 15, P<0.001), C2M2 malignment by 1.7 mm (± 1.2, P<0.001), second tarsometatarsal joint dorsal step-off sign by 0.8 mm (± 0.7, P<0.001), and arch height by 2.5 mm (± 6.4, P<0.048), all greater on the injured side. In the HV group, side-to-side measurements were not significantly different. There was no significant difference comparing the M1M2 measurement in the HV group with the injured (P = 0.16) or uninjured (P = 0.08) foot in the Lisfranc group. The optimal cut-off points were between the injured and uninjured foot in the Lisfranc group were 2.1 mm for C1M2 diastasis, 0.7 mm for the C2M2 alignment, and 30 mm² for the C1M2 surface area. The ICC-score for the second C1M2 area measurement was 0.88.ConclusionBilateral foot weightbearing radiographs can effectively diagnose ligamentous Lisfranc instability using a standardized measurement protocol. Malalignment of the medial aspect of the second metatarsal base ≥0.3 mm relatively to the intermediate cuneiform offers a high sensitivity, and distance ≥2.1 mm between the second metatarsal base and the medial cuneiform has a high specificity. Intermetatarsal distance between the first and second metatarsal base has a low sensitivity and specificity and should not be used in solitary for diagnosis.Level of evidenceLevel III, retrospective comparative study     

Clinical significance of ostial great saphenous vein reflux.

PURPOSE: To evaluate anatomical and haemodynamic differences in patients with great saphenous vein (GSV) insufficiency by duplex scanning and air plethysmography. MATERIAL AND METHODS: Duplex scanning and air plethysmography examination were undertaken. One hundred and twenty-one limbs in 91 patients were selected prospectively and divided into three groups: group A consisted of 27 controls; group B consisted of 25 limbs with GSV reflux and normal saphenous femoral junction (SFJ) and group C consisted of 69 limbs of patients with GSV and SFJ reflux. The presence of reflux and GSV diameter (SFJ, proximal and medial thirds of the thigh, the knee and medial and distal thirds of the calf) were assessed by duplex scanning. Air plethysmography was used to evaluate haemodynamic parameters: total venous volume (VV), venous filling index (VFI), residual volume fraction (RVF) and ejection fraction (EF). RESULTS: There was a significant difference in GSV diameter among the three groups in almost all segments evaluated (e.g. medial thigh group A = 2.4 SD 0.3 mm; B = 3.2 SD 0.7 mm; C = 5.9 SD 2.2mm p<0.001, Anova). A significant difference in VFI was found among the groups (group A = 1.2 SD 0.5; B = 2.0 SD 1.4; C = 4.0 SD 2.5 p<0.05, Anova). VV was statistical different between groups A and C (p = 0.004) and B and C(p = 0.03). EF and RVF were comparable in all groups. The VFI was normal in 68% in group B comparing with only 14.5% in group C patients, finding a reflux more than 5ml/s (determined by VFI) in 26.1% of the group C patients, comparing with only 4% of group B patients (p<0.05). CONCLUSION: We have shown that in patients with GSV reflux those with incompetence of the ostial valve of the GSV show greater venous reflux and dilatation of the saphenous trunk than those in whom the ostial valve is competent.     

Limb Length Discrepancy in Total Hip Arthroplasty: Is the Lesser Trochanter a Reliable Measure of Leg Length?

BackgroundLimb length discrepancy (LLD) after total hip arthroplasty may affect clinical outcomes and patient satisfaction. Preoperative LLD estimates on anteroposterior pelvic radiographs fail to account for anatomical limb variation distal to the femoral reference points. The objective of this study is to determine how variations in lower limb skeletal lengths contribute to true LLD.MethodsFull-length standing anteroposterior radiographs were used to measure bilateral leg length, femoral length, and tibial length. Leg length was evaluated using 2 different proximal reference points: the center of the femoral head (COH) and the lesser trochanter (LT). Mean side-to-side discrepancy (MD) and percentage asymmetry (%AS) for each measurement were evaluated in the overall cohort and when stratified by patient demographic variables.ResultsOne hundred patients were included with an average age of 62.9 ± 11.2 years. Average femoral length was 434.0 ± 39.8 mm (MD 4.3 ± 3.5 mm) and tibial length was 379.9 ± 34.6 mm (MD 5.9 ± 12.7 mm). Average COH-talus was 817.5 ± 73.2 mm (MD 6.4 ± 5.1 mm). Average LT-talus was 760.5 ± 77.6 mm (MD 5.8 ± 5.1 mm). Absolute asymmetry >10 mm was detected in 16% of patients for COH-talus and 15% for LT-talus, while %AS >1.5% was detected in 13% of patients for COH-talus and 18% for LT-talus. Female gender was associated with increased femoral length %AS (P = .037).ConclusionApproximately 1 in 6 patients have an LLD of >10 mm when measured from either the LT or COH. Surgeons using either of these common femoral reference points to estimate LLD on pelvic radiographs should consider these findings when planning for hip reconstruction.Level of EvidenceLevel III.     

Pelvic incidence is a risk factor for lower instrumented vertebra failure in adult spinal deformity patients who underwent corrective fusion terminating at the L5 vertebra

BackgroundFactors related to postoperative mechanical failure after long fusion with lower instrumented vertebra (LIV) at L5 have not been well investigated. Elucidating such factors may allow us to perform alternatives to spinopelvic fusion for adult spinal deformity (ASD) cases. We investigated the incidence and risk factors of LIV failure in patients with ASD who underwent surgical treatment of long corrective fusion until the L5 vertebrae.MethodsBetween 2009 and 2018, 52 patients who underwent corrective fusions to L5 were followed-up for at least one-year. We evaluated the associated patient factors for LIV failure which include loosening of the pedicle screw of LIV, fracture of LIV, distal junctional kyphosis (DJK).ResultsThe mean age of the participants was 71.2 ± 7.59 (range, 44–84). LIV failure occurred in 20 patients (38.5%), and 6 patients (11.5%) underwent secondary surgery for caudal segments. The mean pelvic incidence (PI) was 52.5 ± 9.8 in the failure group versus 45.3 ± 11.4 in non-failure group (P = 0.02) and pelvic tilt (PT) was 39.1 ± 9.0 versus 32.4 ± 13.0. There were no significant differences in sex, age, body mass index, number of levels fused, and other radiographic data. Logistic regression analysis that included T1 pelvic angle, PT, PI - postoperative LL and PI also identified PI as the only significant determinant of LIV failure (OR = 1.07, P = 0.034). Receiver operating characteristic analysis demonstrated that a PI over 50.0° was associated with LIV failure (sensitivity 63%, specificity 70%, AUC 0.694).ConclusionLIV failure was frequently observed after long corrective fusion for patients with ASD. High PI was found to be a significant risk factor for the LIV failure.     

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.)