Severe juxtahepatic venous injury: survival after prolonged hepatic vascular isolation without shunting

Survival following major juxtahepatic venous injury is rare in blunt liver trauma despite the use of intracaval shunting. Prolonged liver arterial inflow control, total hepatic venous isolation and lobectomy without shunting was used in a patient to repair a combined vena caval and hepatic venous injury after blunt liver injury. An extended period of normothermic hepatic ischemia was tolerated. Early recognition of retrohepatic venous injury and temporary liver packing to control bleeding and correct hypovolemia are essential before caval occlusion. Hepatic vascular isolation without shunting is an effective simple alternative technique allowing major venous repair in complex liver trauma.     

Hemodynamics of cardiac tamponade: early recognition from jugular venous flow velocity.

An experimental study was undertaken to determine the effect of cardiac tamponade on peak jugular venous flow velocity (JVFV). Tamponade was produced in seven dogs by incremental infusion of saline into the pericardial cavity while right atrial pressure, right ventricular pressure, pericardial pressure, aortic pressure, electrocardiogram cardiac output, respiration and directional jugular venous flow velocity was monitored. The development of tamponade was associated with an increase in venous and pericardial pressure. Aortic pressure and cardiac output declined progressively. The control JVFV averaged 14 cm/sec and declined markedly during tamponade before other hemodynamic parameters had changed significantly. A 10% decline in mean aortic pressure was associated with a decrease in JVFV to 53% of control. Jugular venous flow velocity had decreased markedly before pericardial pressure or venous pressure had risen into a range suggestive of tamponade. This study documents the marked reduction in JVFV early in the course of cardiac tamponade which can be easily monitored with a directional Doppler velocity detector.     

Deep venous thrombosis in peripheral vascular disease.

BACKGROUND: This prospective study aimed to determine the prevalence of lower limb deep venous thrombosis in patients with peripheral vascular disease (PVD). METHODS: Some 136 patients admitted for arteriography, angioplasty or arterial reconstruction with limiting claudication (n = 72), ischaemic rest pain (n = 26) or gangrene (n = 38) and 40 control subjects admitted for general surgical procedures but without evidence of PVD were screened with colour duplex ultrasonography for the presence of venous thrombosis in the lower limb deep veins before any surgical or radiological procedures were undertaken. Patient age, the ankle : brachial pressure index (ABPI) and the presence of other risk factors for venous thromboembolism were also recorded. RESULTS: Venous thrombosis was found in 27 of 136 patients with PVD and two of 40 control patients (P = 0.03). Logistic regression analysis demonstrated that decreasing ABPI independently contributed to an increased risk of deep venous thrombosis. CONCLUSION: There was a high prevalence of venous thrombosis among patients with PVD which was related to the severity of the ischaemia. Presented to the South West Vascular Surgeons Meeting in Newport, UK, March 1998     

Continuous ambulatory venous pressure for diagnosis of venous insufficiency. Preliminary report

We have found that the venous pressure slope during minimal exercise is a sensitive measurement of venous disease. This parameter differed greatly in our two study populations. Due to increased venous pressure, venous insufficiency syndrome patients have a greater volume of pooled blood, which results in smaller pressure changes with each muscle contraction. In patients with incompetent valves, blood flows in a retrograde fashion in the vein, which leads to a higher steady state minimal pressure and notably to a decreased venous pressure slope. Venous pressure slope is a particularly sensitive measurement and a good prognosticator of venous insufficiency syndrome before symptoms become disabling to the patient. Our data indicate a strong correlation between venous pressure slope and venographic results. In fact, patients with abnormal venographic results invariably have demonstrated venous pressure slopes in the abnormal range.     

Altered venous function and deep venous thrombosis following proximal femoral fracture

The effect of surgery for femoral neck fracture on lower limb venous blood flow and its relationship to deep vein thrombosis was investigated in 179 patients. Blood flow was measured using strain gauge plethysmography before surgery, in the 1st week after surgery, and at 6 week review. There was a significant reduction in both venous outflow and venous capacitance, affecting both fractured and non-fractured legs but significantly greater in the fractured leg. Venous function remained significantly impaired in both lower limbs 6 weeks after surgery.There was a significant correlation between the reduction in venous function and the development of deep vein thrombosis.     

生长抑素对兔大部分肝切除术后门静脉压力的影响

目的探讨生长抑素对肝切除术后门静脉压力的影响。方法32只家兔随机分成正常对照组、生理盐水组、生长抑素组，并建立门静脉置管及肝切除动物模型。术中及术后持续给药，比较各组间门静脉压力的差值。结果与生理盐水组比较，生长抑素组肝切除术前与术后门静脉压力的差值显著减少（P=0．003）。结论生长抑素可明显降低肝切除术后升高的门静脉压力，而且其降压作用是持续而稳定的。     

Insertion of the inferior vena cava filter followed by iliofemoral venous thrombectomy for ischemic venous thrombosis

An elderly man, with ischemic venous thrombosis of the left lower extremity, underwent insertion of the inferior vena cava filter through the right internal jugular vein, followed by left iliofemoral venous thrombectomy with the Fogarty balloon catheter, both with fluoroscopic guidance. The inferior vena cava filter was inserted before venous thrombectomy to prevent pulmonary embolism from dislodged clots during the latter procedure.     

Patients with venous stasis ulceration have increased monocyte-platelet aggregation

Purpose: Leukocyte activation has been implicated in the pathogenesis of venous stasis ulceration, but the involvement of activated platelets and leukocyte-platelet aggregates has not been previously investigated. The purpose of this study was to determine whether patients with venous stasis ulceration have increased platelet activation and a propensity toward formation of leukocyte-platelet aggregates. Methods: Blood was drawn from the superficial veins of the leg just proximal to a venous stasis ulcer and from an antecubital vein in 14 patients with venous stasis ulceration. Blood was also drawn from the antecubital vein of 14 volunteers without evidence of venous disease. Whole-blood flow cytometry was used to analyze the samples before and after activation with a panel of agonists for evidence of platelet activation and the formation of leukocyte-platelet aggregates. Results: Patients with venous stasis ulceration had a greater number of monocyte-platelet aggregates in both the arm and leg samples than did the control subjects (p < 0.01). Furthermore, antecubital blood samples from patients with venous stasis ulceration stimulated with either thrombin-receptor agonist peptide, adenosine diphosphate, or phorbol myristate acetate formed more monocyte-platelet aggregates than did control samples (p < 0.05). No differences in platelet activation or neutrophil-platelet aggregate formation were noted among the three sample groups. Conclusions: Patients with venous stasis ulceration have an increase in the number of monocyte-platelet aggregates in systemic venous blood as well as in venous blood adjacent to a venous stasis ulcer, implicating the monocyte as the leukocyte involved in the pathogenesis of venous stasis ulceration. No association was identified between the presence of a venous stasis ulcer and either neutrophil-platelet aggregation or the activation of individual platelets. Because platelet activation is necessary for the formation of monocyte-platelet aggregates, these data also suggest that monocyte-platelet aggregation is a more sensitive marker for in vivo platelet activation than is the identification of individual activated platelets. (J Vasc Surg 1998;27:1109-16.)     

Asplenia syndrome with total anomalous pulmonary venous connection

Three patients of asplenia syndrome with total anomalous pulmonary venous connection (TAPVC) were reported. Case 1 with exceeding pulmonary blood flow, underwent TAPVC repair and pulmonary artery banding as a first palliation before bi-directional Glenn shunt. Case 2 did not require any surgery to control the pulmonary blood flow before the simultaneous procedure of TAPVC repair and bi-directional Glenn shunt. Case 3 with decreased pulmonary blood flow underwent a complicated course with 3 times of Blalock-Taussig shunts and the repair of TAPVC to prepare for bi-directional Glenn shunt. Simultaneous repair of TAPVC with the procedure which aimed to control the pulmonary blood flow at the first palliation surgery will simplify the control of pulmonary blood flow and prepare good condition of the lung for the Fontan operation in the future.     

Deep venous valve reconstruction

The place of deep venous valve reconstruction in the surgical management of the patient with chronic venous insufficiency has become clearer with collected experience over the past 25 years. The reasons to perform surgery in chronic venous disease and the specific rationale for deep venous repair are contrasted with the management of the same patient by medical means. A new classification of chronic venous disease has been developed and provides the basis for a more objective understanding of specific entities in the entire field of chronic venous symptoms. The requirements for diagnosis before reconstructive surgery are stringent and a diagnostic algorithm is discussed in the selection of candidates for deep venous reconstruction. The multiple surgical techniques for deep venous reconstruction include internal intravenous direct valve repair and extravenous tightening of the vein wall around the valve cusp. The results of valve repair for primary valve incompetence are discussed in terms of long-term clinical results, long-term imaging results and long-term physiologic results as reflected by venous pressure examinations. It is becoming increasingly clear with the passage of time and the sharpening of our diagnostic skills that reflux is the dominant cause of chronic venous insufficiency. The ability of surgical procedures to decrease reflux in a diseased extremity can be used to restore patients to their normal way of life free of pain, swelling and ulceration and, in the ideal case, free of the need for elastic support.     

低中心静脉压在肝叶切除术中的应用

目的研究低中心静脉压技术是否能降低肝叶切除术中的出血量,并评价这一技术对肾功能的影响。方法60例择期行肝叶切除术的病人。随机均分为对照组和低中心静脉压(LCVP)组。均采用静吸复合气管插管全麻。LCVP组通过吸入异氟醚,静注芬太尼,切肝前控制输液量,必要时微泵静注硝酸甘油,将CVP控制在4 mmHg左右。观察两组病人术中出血量、输血量、切肝前输液量和收缩压、以及术后24h肾功能变化。结果LCVP组术中出血量、输血量、切肝前输液量和收缩压均低于对照组(P<0.05)。术后24h两组病人肾功能变化无显著性差异(P>0.05)。结论低中心静脉压技术可减少肝叶切除术中的出血量及输血量,且对肾功能无明显影响。     

Muscle changes in venous insufficiency

The diagnosis of venous insufficiency and hypertension was established in 53 patients using standard diagnostic methods including ascending and descending venography, venous pressure measurements, and photoplethysmography. Autogenous vein valve transplant, which is gaining acceptance as a treatment for this condition, was employed in this group of patients to relieve venous valvular insufficiency. Biopsy specimens of the gastrocnemius muscle were obtained before surgery in all 53 patients and studied pathologically. Three types of morphologic injury were encountered, suggesting that disuse, denervation, and ischemia may each be partially responsible for damage in skeletal muscle subjected to venous insufficiency and hypertension. Skeletal muscle injury probably explains the preoperative elevations of serum creatine kinase levels in many of our patients and may account for the failure of venous pressures to return to normal levels following surgery.     

静脉高压对慢性静脉功能不全患者血小板活性的影响

目的 观察体位变化和压力对下肢慢性静脉功能不全(CVI)患者血小板活性的影响.方法 根据纳入和排除标准,选择24例CVI患者作为实验组和20例正常人作为对照组,采用酶联免疫吸附法(ELISA)测定两组人群在不同体位时下肢静脉血液、肘部静脉血液及在外在压力持续作用60 min后血小板P-选择素表达水平.结果 晨起平卧位及站立30 min后两组下肢静脉血液血小板P-选择素表达水平差异无统计学意义(P>0.05);在90～100mm Hg(1 mmHg=0.133 kPa)压力作用60 min后,CVI患者的下肢静脉血液和肘部静脉血液血小板P-选择素均明显高于对照组(P<0.01).结论 CVI患者血小板对压力具有高反应性,可能是CVI发病的重要机制之一.     

Residual venous reflux after superficial venous surgery does not predict ulcer recurrence.

OBJECTIVE: The aim of this study was to investigate the importance of venous reflux in ulcer recurrence following saphenous surgery. METHODS: Ulcerated legs (CEAP 5 and 6) with saphenous reflux were treated with superficial venous surgery plus compression as part of a clinical trial. Patients unfit for general anaesthesia (GA) underwent limited surgery under local anaesthesia (LA). Reflux in superficial and deep segments and venous refill times (VRTs) were assessed before surgery and 3-12 months post-operatively using duplex and digital photoplethysmography respectively. RESULTS: Of 185 patients treated with surgery, 15 failed to heal and 26 did not have a follow-up duplex. Within 3 years, 25 of the remaining 144 patients (17%) developed ulcer recurrence. Using a Cox regression model, the presence of residual venous reflux and change in reflux pattern were not found to be risk factors for ulcer recurrence (p=ns). LA was used in 4/25 patients who recurred compared to 28/119 who did not (p=0.60; Chi-square test). For legs with recurrence, median VRT before surgery was 10.5s (range 5-29) compared to 11s (range 6-36) after surgery (p=0.097, Wilcoxon Signed Rank test). However, in legs without recurrence, median VRT increased from 10s (range 3-48) to 15s (range 4-48) after surgery (p<0.001). CONCLUSION: Residual reflux following saphenous surgery is not the most important predictor of venous ulcer recurrence. Poor venous function as demonstrated by VRT may be a better predictor of recurrence in these patients.     

Successful iliac vein and inferior vena cava stenting ameliorates venous claudication and improves venous outflow, calf muscle pump function, and clinical status in post-thrombotic syndrome

OBJECTIVES: Stent therapy has been proposed as an effective treatment of chronic iliofemoral (I-F) and inferior vena cava (IVC) thrombosis. The purpose of this study was to determine the effects of technically successful stenting in consecutive patients with advanced CVD (CEAP3-6 +/- venous claudication) for chronic obliteration of the I-F (+/-IVC) trunks, on the venous hemodynamics of the limb, the walking capacity, and the clinical status of CVD. These patients had previously failed to improve with conservative treatment entailing compression and/or wound care for at least 12 months. METHODS: The presence of venous claudication was assessed by > or =3 independent examiners. The CEAP clinical classification was used to determine the severity of CVD. Outflow obstruction [Outflow Fraction at 1- and 4-second (OF1 and OF4) in %], venous reflux [Venous Filling Index (VFI) in mL/100 mL/s], calf muscle pump function [Ejection Fraction (EF) in %] and hypertension [Residual Venous Fraction (RVF) in %], were examined before and after successful venous stenting in 16 patients (23 limbs), 6 females, 10 males, median age 42 years; range, 31-77 yearas, left/right limbs 14/9, using strain gauge plethysmography; 7/16 of these had thrombosis extending to the IVC. Contralateral limbs to those stented without prior I-F +/- IVC thrombosis, nor infrainguinal clots on duplex, were used as control limbs (n = 9). Excluded were patients with stent occlusion or stenoses, peripheral arterial disease (ABI <1.0), symptomatic cardiac disease, unrelated causes of walking impairment, and malignancy. Preinterventional data (< or =30 days) were compared with those after endovascular therapy (8.4 months; interquartile range [IQR], 3-11.8 months). Nonparametric analysis was applied. RESULTS: Compared with the control group, limbs with I-F +/- IVC thrombosis before stenting had reduced venous outflow (OF4) and calf muscle pump function (EF), worse CEAP clinical class, and increased RVF (all, P < 0.05). At 8.4 months (IQR, 3-11.8 months) after successful I-F (+/-IVC) stenting, venous outflow (OF1, OF4) and calf muscle pump function (EF) had both improved (P < 0.001) and the RVF had decreased (P < 0.001), at the expense of venous reflux, which had increased further (increase of median VFI by 24%; P = 0.002); the CEAP status had also improved (P < 0.05) from a median class C3 (range, C3-C6; IQR, C3-C5) [distribution, C6: 6; C4: 4; C3: 13] before intervention to C2 (range, C2-C6; IQR, C2-C4.5) [distribution, C6: 1; C5: 5; C4: 4; C2: 13] after intervention. At this follow up (8.4 months median), venous outflow (OF1, OF4), calf muscle pump function (EF), and RVF of the stented limbs did not differ significantly from those of the control; significantly worse (P < 0.025) were the amount of venous reflux (VFI), and the CEAP clinical class, despite the improvement with stenting. Incapacitating venous claudication noted in 62.5% (10 of 16, 95% CI, 35.8%-89.1%) of patients (15 of 23 limbs; 65.2%, 95% CI, 44.2%-86.3%) before stenting was eliminated in all after stenting (P < 0.001). CONCLUSIONS: Successful I-F (+/-IVC) stenting in limbs with venous outflow obstruction and complicated CVD (C3-C6) ameliorates venous claudication, normalizes outflow, and enhances calf muscle pump function, compounded by a significant clinical improvement of CVD. The significant increase in the amount of venous reflux of the stented limbs indicates that elastic or inelastic compression support of the successfully stented limbs would be pivotal in preventing disease progression.     

Percutaneous venous cannulation and central venous line placement by means of ultrasonography and ultrasonic Doppler

Ultrasonography is being increasingly used in the field of anesthesiology. One major indication is visualization of central venous vessels, in particular the internal jugular vein before and during cannulation by means of ultrasonography or ultrasonic Doppler. This should facilitate puncture with a higher rate of successful cannulations and decreased rate of complications related to needle probing during catheterization attempts. Furthermore, by using ultrasonography central venous catheters can be located in the vessels. The picture quality of various central venous catheters currently used in anesthesia and intensive care does not show any noticeable difference.     

戴戒术与单纯浅静脉剥脱术治疗原发性下肢深静脉瓣膜功能不全的比较

目的:比较股浅静脉戴戒术与单纯性浅静脉剥脱术治疗下肢深静脉瓣膜功能不全的疗效。方法:将2010年03月—2011年1月收治的48例下肢深静脉瓣膜功能不全伴静脉曲张患者随机分为观察组(股浅静脉戴戒术联合大隐静脉高位结扎剥脱术)和对照组(传统大隐静脉高位结扎剥脱术),通过彩色多普勒检测两组术前及术后股总静脉血管内径、平均血流速度及Valsalva试验下反流持续时间的变化。结果:与术前比较,术后两组患者的静脉瓣膜功能及血流动力学均明显改善,表现为股总静脉管径缩小、平均血流速度增快、静脉血流反流时间缩短(均P<0.05),但观察组上述3个变量手术前后变化程度(差值)均明显大于照组(均P<0.05)。结论:两种手术方式均是治疗下肢深静脉瓣膜功能不全的有效手段,但戴戒术的治疗效果优于单纯性浅静脉剥脱术。     

Changes in venous endothelial fibrinolytic activity and histology with in vitro venous distention and arterial implantation

We performed intraoperative pressure monitoring in a clinical setting and demonstrated that the average venous distention pressure observed during preparation of autogenous vein grafts for arterial implantation was 300 to 500 mm Hg and often exceeded 500 mm Hg. Similar data on venous distention pressures were obtained by Ramos et al [4] and by Abbott et al [1]. Although the exact relation between venous distention pressure, venous endothelial fibrinolytic activity and long-term autogenous vein graft patency is unknown, our data suggest that autogenous vein graft distention pressure should be kept under 500 mm Hg during graft procurement and static pressure testing before venous autograft implantation. Ideally, either venous distention pressure should be monitored during vein graft harvesting and preparation, and kept as low as possible, or procured autogenous vein grafts should not be statically distended but rather allowed to gradually enlarge due to pulsatile arterial flow after implantation.     

腹腔镜胆囊切除术中气腹后中心静脉压的变化

目的观察腹腔镜下胆囊切除术中气腹后中心静脉压的变化情况,探讨其临床意义。方法无其他因素影响中心静脉压的30例病例行腹腔镜下胆囊切除术,观察二氧化碳气腹前、中、后中心静脉压的变化情况。结果二氧化碳气腹后中心静脉压明显升高,但仍在正常范围内,停止气腹后,中心静脉压快速恢复至术前水平。结论行腹腔镜下胆囊切除术时,二氧化碳气腹后的中心静脉压增加对循环系统功能影响不明显,仍在机体代偿范围,无常规检测的必要。     

激光闭合穿通支静脉治疗下肢静脉溃疡

目的 探讨激光闭合穿通支静脉在下肢静脉性溃疡治疗中的作用。方法 以2014年1月至2015年12月收治的28例下肢静脉溃疡（28条肢体）。所有病人均行CT静脉成像定位溃疡处穿通支静脉。14例行大（小）隐静脉高位结扎+穿通支静脉激光闭合术（激光组）,另14例行大（小）隐静脉高位结扎+穿通支静脉结扎术（对照组）。术后均以弹力袜加压并定期处理溃疡创面,随访2年。结果 两组病人一般情况无统计学差异。术前溃疡病程和溃疡面积均无统计学差异。激光组术后1周溃疡面积缩小值明显大于常规组（P<0.05）,1个月和2个月的溃疡面积缩小值无差异。对照组有6例发生切口愈合不良,高达42.9%,而激光组仅1例出现局部灼伤。两组间有明显统计学差异（P<0.01）。2个月内溃疡愈合的比例在两组间无差异,均为12例（85.7%）。两组1年内溃疡复发率亦无统计学差异（P>0.05）,1~2年内均无复发。结论 在大（小）隐静脉结扎的基础上,激光闭合穿通支静脉可有效促进溃疡愈合。