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.     

Randomised Controlled Trial Comparing Sapheno-Femoral Ligation and Stripping of the Great Saphenous Vein with Endovenous Laser Ablation (980 nm) Using Local Tumescent Anaesthesia: One Year Results

ObjectivesComparison of sapheno-femoral ligation and stripping (SFL/S) versus endovenous laser ablation (EVLA, 980-nm) in the treatment of great saphenous vein (GSV) insufficiency, using local tumescent anaesthesia.DesignRandomised, single centre trial.Materials and methodsPatients with GSV incompetence and varicose veins were randomised to either SFL/S or EVLA. At days 1, 2, 3, 7, 10, and 14 post-treatment, patients completed questionnaires on pain and quality of life. Recurrent varicose veins were evaluated by Duplex ultrasound (DUS) performed at 1 and 6 weeks, and 6 and 12 months.Results130 legs in 121 patients were treated by SFL/S (n = 68) or EVLA (n = 62). Significantly more post-treatment pain was noted after EVLA at days 7, 10 and 14 (p < 0.01; p < 0.01; p = 0.01), more hindrance in mobility at days 7 (p < 0.01) and 10 (p = 0.01), and in self care (p = 0.03) and daily activities (p = 0.01) at day 7 compared to SFL/S. DUS at 1-year follow-up showed 9% recurrences (5/56) after EVLA and 10% (5/49) after SFL/S.ConclusionBoth SFL/S and EVLA, using local tumescent anaesthesia, were well tolerated, with no difference in short-term recurrence rate. In the second week after EVLA, patients experienced significantly more pain resulting in restricted mobility, self care and daily activity compared to SFL/S.     

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.     

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

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

Fate and clinical significance of saphenofemoral junction tributaries following endovenous laser ablation of great saphenous vein

BACKGROUND: Unlike surgery, endovenous laser ablation (EVLA) abolishes great saphenous vein (GSV) reflux but does not specifically interrupt the GSV tributaries at the groin. The fate and clinical significance of these tributaries were assessed in a prospective study. METHODS: Eight-one legs (70 patients) underwent colour flow duplex ultrasonography 12 months after GSV ablation for primary varicose veins. Saphenofemoral junction (SFJ) reflux, tributary patency, and recurrent or residual varicosities were recorded, and Aberdeen Varicose Vein Severity Scores (AVVSS) were compared with pretreatment values. RESULTS: The GSV had recanalized without evidence of reflux in two patients. None of the 81 legs showed SFJ reflux although one or more patent tributaries were visible in 48 (59 per cent); all were competent. In 32 legs (40 per cent) there was flush GSV occlusion with the SFJ and no tributaries were detectable. One leg showed evidence of neovascularization in the groin. AVVSS values were similar in groups with or without visible tributaries, both before and after EVLA: median (interquartile range) 13.9 (7.6-19.2) before EVLA and 2.9 (0.6-4.8) at follow-up in patients with visible tributaries, and 14.9 (9.2-20.2) and 3.1 (0.8-5.1) respectively in those without. Recurrent varicosities were present in one leg only, due to an incompetent mid-thigh perforating vein. CONCLUSION: Persistent non-refluxing GSV tributaries at the SFJ did not appear to have an adverse impact on clinical outcome 1 year after successful EVLA of the GSV.     

Laser and Radiofrequency Ablation Study (LARA study): A Randomised Study Comparing Radiofrequency Ablation and Endovenous Laser Ablation (810 nm)

ObjectivesThere have been few randomised studies comparing Radiofrequency Ablation(RFA) with other endovenous techniques. The primary aim of this study was to determine whether RFA of the great saphenous vein (GSV) was associated with less pain and bruising than endovenous laser ablation (EVLA).Materials and methodsThis trial had two cohorts – patients with bilateral GSV incompetence causing varicose veins (VV) and those with unilateral GSV VVs. In total 87 legs were treated in this study. Limbs in the bilateral group were treated with RFA in one leg and EVLA in the other. In the unilateral group limbs were randomised to RFA or EVLA. RFA was performed using the Celon RFiTT system (Teltow, Germany). EVLA was performed using an 810 nm Laser (Biolitec AG, Germany). Phlebectomies were performed as required. Primary endpoints were patient assessed pain and bruising measured by visual analogue scale (VAS). Secondary endpoints were patency assessed by duplex ultrasound at 6 weeks and 6 months.ResultsIn the bilateral group, RFA resulted in significantly less pain than EVLA on days 2–11 postoperatively. RFA also resulted in significantly less bruising than EVLA on days 3–9. There were no significant differences in mean post operative pain, bruising and activity scores in the unilateral group. Both RFA and EVLA resulted in occlusion rates of 95% at 10 days postoperatively.ConclusionsRFA was less painful for patients than EVLA and produced less bruising in the postoperative period with comparable success rates but there was no difference in the unilateral group.     

Preclinical Development of Tissue-Engineered Vein Valves and Venous Substitutes using Re-Endothelialised Human Vein Matrix

ObjectiveThe aim of the study was to evaluate the use of a decellularised scaffold and its re-endothelialisation in vitro in order to create human vascular substitutes containing venous valves. This research is clinically relevant particularly with regard to the development of venous (valve containing) transplants to replace a diseased femoral vein valve and/or obstructed veins. This technique may enable causal treatment of venous reflux and obstructions.Materials and methodsValve-bearing segments of human allogeneic great saphenous veins (GSVs) were decellularised using sodium deoxycholic acid (SD) and treated with DNase I. Human venous endothelial cells (ECs) were enzymatically harvested from the GSV, expanded up to the 3rd passage using FCS (n = 20) or human AB serum (hABS; n = 8) supplemented media before used for re-seeding. In special bioreactors, 3D re-seeding of 28 decellularised GSV was performed with constant perfusion (A; n = 8), bidirectional perfusion (B; n = 8), bidirectional perfusion/reduced flow (C; n = 2), static conditions (D; n = 2), and bidirectional perfusion/reduced flow using hABS (E; n = 8) instead of FCS. Decellularised GSV, scaled-up EC and 3D-seeded tissue-engineered valve containing neo-veins underwent immunohistochemical and PCR characterisation.ResultsIntact collagen and elastin networks as well as complete acellularity were shown after GSV decellularisation. In EC culture, supplementation with hABS led to a significantly higher expression of vWF compared to FCS (p = 0.025). Additional EC markers such as CD 31, FLK-1 and VE-Cadherin were not altered. EC re-seeding using hABS supplemented medium (E) led to a confluent monolayer of cells that were immunohistochemically positive for FLK-1, CD 31, vWF and VE-Cadherin and by means of PCR after RNA preparation in 7 of 8 cases but was unsuccessful if FCS was used (A–D). In A–D cells presented as conglomerates positive for CD 31 and VE-Cadherin, suggesting sufficient intercellular contact but not cell–matrix contact.ConclusionsTreatment with SD and DNase enables complete decellularisation of human valve containing veins whereas 3D matrix components such as collagen and elastin remain preserved. The lumen of the scaffold including the valves can be successfully re-seeded with a human EC monolayer in a 3D bioreactor. There is substantial evidence that hABS and not FCS is essential for the completion of cell–matrix contacts in human veins.     

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

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

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.     

Perioperative complications and oncological safety of robot-assisted (RARC) vs. open radical cystectomy (ORC)

ObjectivesTo assess the surgical and oncological outcome of robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC).Patients and methodsClinical data of 64 patients undergoing RARC between August 2010 and August 2013 were prospectively documented and retrospectively compared with 79 patients undergoing ORC between August 2008 and August 2013 at a single academic institution. Perioperative results, surgical margins status, and nodal yield after RARC and ORC were compared using Mann-Whitney U test (continuous variables) and chi-square test (categorical variables). Additional age-stratified analysis was performed in elderly patients (≥75 y). To avoid inference errors by multiple testing, P-values were adjusted using Bonferroni?s correction.ResultsBaseline characteristics of both cohorts were balanced. RARC patients had significantly less blood loss (RARC: 300 [interquartile range {IQR}: 200–500] ml; perioperative transfusion rate: 0 [IQR: 0–2] red packed blood cells [RPBCs]; ORC: 800 [IQR: 500–1200] ml, P<0.01; transfusion rate: 3 [IQR: 2–4] RPBCs, P<0.01), and hospital stay of RARC patients was reduced by 20% (RARC: 13 [IQR: 9–17] d, ORC: 16 [IQR: 13–21] d, P< 0.01).A total of 55 patients who underwent RARC and 59 patients who underwent ORC were eligible for analysis of oncological surrogates “surgical margin status” and “lymph-node yield” as well as for survival data. No differences between patients undergoing RARC or ORC were observed.In elderly patients (≥75 y; RARC: 17 patients, ORC: 28 patients), decreased intraoperative blood loss (RARC: 300 [IQR: 100–475] ml; ORC: 800 [IQR: 400–1300] ml, P<0.01) and lower transfusion rate (RARC: 0 [IQR: 0–1] RPBCs; ORC: 4 [IQR: 2–5] RPBCs, P<0.01) were observed in the robotic group.Major limitations of this study are the retrospective study design and a potential selection bias.ConclusionsRARC provides significant advantages compared with ORC regarding blood loss and postoperative recovery, whereas surgical and oncological outcomes are not different.     

Balloon Angioplasty as the Primary Treatment for Failing Infra-inguinal Vein Grafts

BackgroundWe sought to evaluate the role of balloon angioplasty as the primary modality in the management of vein graft stenoses.MethodsPatients who underwent infrainguinal vein graft bypass from January 2002 to December 2007 were enrolled into a surveillance program. Grafts which developed critical stenoses were identified and underwent urgent angiography with a view to angioplasty of the stenotic lesion. Lesions which were deemed unsuitable for angioplasty underwent urgent surgical repair.ResultsFour hundred and eleven grafts were followed up for a median of 19 months (range: 2–61). Ninety-six grafts (22.6%) developed critical stenosis. Twelve grafts occluded prior to repair and one was not intervened upon electively. Eight grafts underwent primary surgical repair. Seventy-six grafts underwent 99 endovascular procedures. Technical success was achieved in 60 grafts (78.9%). Of the grafts in which technical success had not been achieved, eight underwent repeat angioplasty and three were surgically repaired. Twenty-four grafts underwent repeat angioplasty for re-stenosis with a technical success rate of 71%. No difference was observed in graft patency (P = 0.08) or amputation rates (P = 0.32) between the grafts requiring intervention to maintain patency, and grafts which did not. Smoking [OR: 2.61 (95% CI: 1.51–4.53), (P = 0.006)], diabetes [OR: 2.55 (95% CI: 1.49–4.35), (P = 0.006)], renal failure [OR: 1.89 (95% CI: 1.19–3.38), (P = 0.040)] and recurrent stenosis [OR: 3.22 (95% CI: 1.63–4.69), (P < 0.001)] were risk factors for graft occlusion.ConclusionsBalloon angioplasty of failing infrainguinal vein bypass grafts is safe and can be performed with an acceptable medium term patency rate, albeit with a significant risk of re-stenosis which can be successfully treated in most patients using repeat endovascular intervention.     

Maintained Geometry,Elasticity and Contractility of Human Saphenous Vein Segments Stored in a Complex Tissue Culture Medium

ObjectiveImproved maintenance of endothelial function and higher viability of saphenous vein grafts stored in a complex tissue culture medium (TCM) have been demonstrated. This article studies the biomechanical properties of saphenous vein segments.DesignBiomechanical properties of 72 saphenous vein segments remaining from coronary bypass grafting of 32 patients have been studied after different storage procedures.MaterialsThe materials studied included fresh segments, segments stored in a cooled conventional physiological salt solution (normal Krebs–Ringer (nKR)) for 1–2 weeks, segments stored in a cooled chemically defined TCM (X-Vivo) for 1,2,3 and 4 weeks and segments cryopreserved for a few weeks.MethodsSpecimens were cannulated at both ends and pressure–diameter curves were recorded in the 0–85-mmHg range in nKR with 10 μM norepinephrine added to induce maximum smooth muscle contraction, as well as in Ca²⁺-free medium to induce full relaxation. Tensile strength was checked at 300 mmHg. Distensibility, elastic modulus and active strain were computed.ResultsSegments stored in nKR dilated morphologically, their distensibility decreased and they lost their ability to contract (1.5 ± 0.7% from 10.1 ± 1.5% of control) in 1 week. The TCM-stored segments preserved their contractility until 1 week, and this parameter only slowly decreased afterwards (first week, 11.5 ± 7.3%; fourth week, 3.9 ± 0.6%). There was a slight decrease in wall thickness but the lumen diameter was not affected. The elastic parameters of these segments were practically identical to those of fresh segments. Cryopreserved segments narrowed morphologically, their wall thickened and contractility diminished.ConclusionsStorage in TCM helps preserve the passive and active biomechanical properties of human saphenous vein segments. Such properties can be expected to improve graft tissue viability.     

Evaluation of an Electromagnetic 3D Navigation System to Facilitate Endovascular Tasks: A Feasibility Study

IntroductionWe describe a novel approach to arterial cannulation using the StealthStation^® Guidance System (Medtronic, USA). This uses electromagnetic technology to track the guidewire, displaying a 3D image of the vessel and guidewire.MethodsThe study was performed on a ‘bench top’ simulation model called the Cannulation Suite comprising of a silicone aortic arch model and simulated fluoroscopy. The accuracy of the StealthStation^® was assessed. 16 participants of varying experience in performing endovascular procedures (novices: 6 participants, ≤5 procedures performed; intermediate: 5 participants, 6–50 procedures performed; experts: 5 participants, >50 procedures performed) underwent a standardised training session in cannulating the left subclavian artery on the model with the conventional method (i.e. with fluoroscopy) and with the StealthStation^®. Each participant was then assessed on cannulating the left subclavian artery using the conventional method and with the StealthStation^®. Performance was video-recorded. The subjects then completed a structured questionnaire assessing the StealthStation^®.ResultsThe StealthStation^® was accurate to less than 1 mm [mean (SD) target registration error 0.56 mm (0.91)]. Every participant was able to complete the cannulation task with a significantly lower use of fluoroscopy with the navigation system compared with the conventional method [median 0 s (IQR 0–2) vs median 14 s (IQR 10–19), respectively; p = <0.001]. There was no significant difference between the StealthStation^® and conventional method for: total procedure time [median 17 s (IQR 9–53) vs median 21 s (IQR 11–32), respectively; p = 0.53]; total guidewire hits to the vessel wall [median 0 (IQR 0–1) vs median 0 (IQR 0–1), respectively; p = 0.86]; catheter hits to the vessel wall [median 0.5 (IQR 0–2) vs median 0.5 (IQR 0–1), respectively; p = 0.13]; and cannulation performance on the global rating scale [median score, 39/40 (IQR 28–39) vs 38/40 (IQR 33–40), respectively; p = 0.40]. The intra-class correlation coefficient for agreement between video-assessors for all scores was 0.99. 88% strongly agreed that the StealthStation^® can potentially decrease exposure of the patient to contrast and radiation.ConclusionArterial cannulation is feasible with the StealthStation^®.     

Anatomical factors predicting lower calyceal stone clearance after extracorporeal shockwave lithotripsy

ObjectiveTo determine the role of the lower pole infundibular parameters as predictors of stone clearance following extracorporeal shock wave lithotripsy (ESWL).Subjects and methodsBetween March 2001 and February 2004, 243 renal units in 239 patients with isolated lower calyceal stones were treated by ESWL. Stone-free status was assessed after 3 months by plain X-ray abdomen and a kidney ultrasound scan. Persistent stone fragments ≥6 months after the completion of treatment was defined as residual stone. Radiogaphic parameters were obtained from intravenous urography (IVU). SPSS version 15.0 was utilized for all statistical analysis.ResultsThe median age of all patients was 38 years (range: 20–70 years). The male to female ratio was 2.1:1.The mean stone size was 1.3 ± 0.7 cm. Overall, 144 renal units (60.9%) had undergone one or two sessions of ESWL, 43 (17.7%) 3, while 46 (18.9%) ≥4 sessions, with mean of 2.1 sessions.Stone-free rates differed significantly between favorable and unfavorable infundibular length (IL), and infundibular width (IW) (p value = 0.01, p = 0.0001, respectively). Infundibulopelvic (IP) angle had no statistically significant effect on stone-free rate (p = 0.1).The effect of stone size on stone-free rate in two groups revealed better overall results in favorable anatomy group than in unfavorable group in stone sizes, 0.5–1.0 cm, 1.1–1.5 cm, 1.6–2 cm and 2.1–2.5 cm (76.7%, 87.5%, 100%, and 56.2% vs. 41.1%, 55.5%, 66.6%, and 50%; p = 0.04, 0.10, 0.10, 0.80, respectively).ConclusionsThis study shows that lower infundibular length and width are significant anatomical factors in determining stone clearance following ESWL treatment of lower calyceal stones and these should be assessed before planning the treatment for lower calyceal stones.     

Factors influencing the effectiveness of endovenous laser ablation (EVLA) in the treatment of great saphenous vein reflux.

OBJECTIVE: Endovenous laser ablation (EVLA) is an alternative to surgery for treating sapheno-femoral and great saphenous vein (GSV) reflux. This study assesses factors that might influence its effectiveness. DESIGN: Prospective, observational study. METHOD: EVLA was used to treat the great saphenous vein in 644 limbs as part of the management of varicose veins. Body mass index (BMI), maximum GSV diameter, length of vein treated, total laser energy (TLE) and energy density (ED: Joules/cm) delivered were recorded prospectively. Data from limbs with ultrasound confirmed GSV occlusion at 3-months were compared with those where the GSV was partially occluded or patent. Complications were recorded prospectively. RESULTS: GSV occlusion was achieved in 599/644 (93%) limbs (group A). In 45 limbs (group B) the vein was partially occluded (n=19) or patent (n=26). Neither BMI [group A: 25.2 (23.0-28.5); group B: 25.1 (24.3-26.2)], nor GSV diameter [A: 7.2mm (5.6-9.2); B: 6.9 mm (5.5-7.7)] influenced success. TLE and ED were greater p<0.01) in group A (median [inter-quartile range]: 1877J (997-2350), 48 (37-59)J/cm) compared to group B (1191J (1032-1406), 37 (30-46)J/cm). Although TLE reflects the greater length of GSV ablated in Group A (33 cm v 29 cm, p=0.06) this does not influence ED. GSV occlusion always occurred when ED>/=60 J/cm with no increase in complications. CONCLUSIONS: ED (J/cm) of laser delivery is the main determinant of successful GSV ablation following EVLA.     

Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care

BackgroundModern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC).MethodsFor this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed.ResultsThe USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p < 0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17–29] vs. 21 [17–26], p < 0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61–1.48, p = 0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2–11] vs. 2 [2–7] days, p = 0.006) but had a shorter hospital stay (median [IQR] 6 [3–13] vs. 8 [4–16] days, p < 0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p < 0.0001), and had a higher readmission rate (8% vs. 4%, p = 0.01).ConclusionAlthough several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.     

Endovascular stenting for chronic femoro-iliac venous obstructive disease: Clinical efficacy and short-term outcomes

PurposeTo report the clinical efficacy and mid-term outcomes of endovascular treatment in patients with chronic, symptomatic, post-thrombotic femoro-iliac venous obstruction.Materials and methodsForty-two patients with post-thrombotic syndrome (PTS) presenting with femoro-iliac venous obstructive lesions treated in our institution by endovascular approach between March 2012 and October 2017 were retrospectively included. There were 27 women and 15 men with a mean age of 47.3 ± 17 (SD) years (range: 22–86 years). Procedure included first venous recanalization, then pre-dilatation and self-expandable metallic stenting of the narrowed or occluded iliac and/or femoral veins. Severity of PTS and quality of life were assessed at baseline and 3 months after the intervention respectively, using Villalta score and Chronic Venous Insufficiency Questionnaire (CIVIQ-20) scale. Imaging follow-up evaluation of stent patency was based on the results of duplex Doppler ultrasound and computed tomography.ResultsImmediate technical success was achieved in 41/42 (97.6%) patients, without any major complications. Primary patency, primary assisted patency and secondary patency at the end of the median imaging follow-up of 18.1 months (IQR, 9.7–34.4) were achieved in 29/42 (66.7%) patients, 33/42 (78.6%) patients and 37/42 (88.1%) patients, respectively. Median Villalta and CIVIQ-20 scores decreased from 14 (IQR, 10–19) and 57 (IQR, 39–72) at baseline, respectively, to 5 (IQR, 2–9) and 30 (IQR, 24–50) 3 months after the procedure, respectively (P < 0.0001), showing significant decrease in the severity of PTS and improvement in the quality of life. The multiple linear regression model showed that both baseline Villalta and CIVIQ-20 scores ([95% CI: −7.80–3.79; P < 0.0001] and [95% CI: 0.07–0.20; P < 0.0001], respectively), age (95% CI: 0.04–0.19; P = 0.002) and stenting expanse (95% CI: 0.97–5.65; P = 0.006) were independent variables related to Villalta gain. Baseline Villalta (95% CI: 0.89–2.23; P < 0.0001) was the single independent variable related to CIVIQ-20 gain.ConclusionThis study confirms the high clinical efficacy and favorable mid-term outcomes of endovascular stenting in patients with chronic symptomatic femoro-iliac venous obstructive lesions.     

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.     

Presurgical sunitinib reduces tumor size and may facilitate partial nephrectomy in patients with renal cell carcinoma

ObjectiveTo determine whether presurgical sunitinib reduces primary renal cell carcinoma (RCC) size and facilitates partial nephrectomy (PN).MethodsData from potential candidates for PN treated with sunitinib with primary RCC in situ were reviewed retrospectively. Primary outcome was reduction in tumor bidirectional area.ResultsIncluded were 72 potential candidates for PN who received sunitinib before definitive renal surgery on 78 kidneys. Median primary tumor size was 7.2 cm (interquartile range [IQR]: 5.3–8.7 cm) before and 5.3 cm (IQR: 4.1–7.5 cm) after sunitinib treatment (P<0.0001), resulting in 32% reduction in tumor bidirectional area (IQR: 14%–46%). Downsizing occurred in 65 tumors (83%), with 15 partial responses (19%). Tumor complexity per R.E.N.A.L. score was reduced in 59%, with median posttreatment score of 9 (IQR: 8–10). Predictors of lesser tumor downsizing included clinical evidence of lymph node metastases (P<0.0001), non–clear cell histology (P = 0.0017), and higher nuclear grade (P = 0.023). Surgery was performed for 68 tumors (87%) and was not delayed in any patient owing to sunitinib toxicity. Grade≥3 surgical complications occurred in 5 patients (7%). PN was performed for 49 kidneys (63%) after sunitinib, including 76% of patients without and 41% with metastatic disease (P = 0.0026). PN was completed in 100%, 86%, 65%, and 60% of localized cT1a, cT1b, cT2, and cT3 tumors, respectively.ConclusionPresurgical sunitinib leads to modest tumor reduction in most primary RCC, and many patients can be subsequently treated with PN with acceptable morbidity and preserved renal function. A randomized trial is required to definitively determine whether presurgical therapy enhances feasibility of PN.     

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.