Subfascial endoscopic perforating vein surgery (SEPS) for the treatment of venous ulcers

Lower extremity ulcerations that result from venous hypertension are a significant cause of disability in Western nations. Venous ulcers, highly related to lower extremity venous valvular incompetence and post-thrombotic syndrome, demonstrate a protracted course of healing with a high recurrence rate when managed conservatively. Effective treatment includes correcting the elevated lower extremity venous pressure using non-invasive (compression therapy) or invasive modalities (removal or correction of incompetent venous segments, most commonly the greater saphenous vein). Minimally invasive subfascial endoscopic perforating vein surgery, performed on an outpatient basis, allows ligation of incompetent Cockett perforating veins. Venous ulcer healing rates of 88% and infrequent wound complications have been reported using this technique. Using 5-mm cameras and trocars that are available for other endoscopic surgeries could further improve this technique; creating ports smaller than the traditional 15-mm incisions would subsequently reduce tissue disruption. In addition, the etiology of recurrent ulceration and the failure of the primary ulcer to heal are not completely understood. If these poor outcomes can be further defined, even higher rates of wound healing may be attained using this procedure. Significant efforts have been devoted to elucidating the exact mechanism of skin breakdown from venous hypertension but the pathophysiology of this process is still not understood.     

The perforating vein of the Hunter's canal: incidence in varicose pathology and treatment]

Hunter's perforator is a vein which joins the great saphenous vein with the femoral vein by passing through the aponeurosis of the adductor (Hunter's) canal, more or less at the junction of the lower and middle thirds of the thigh. It is constant, very variable in terms of its origin and may be twin or more, though there is a degree of regularity concerning its ending. It is important to detect its incontinence in varicose pathology, notably when there is recurrence following stripping of the great saphenous. Clinical examination is the most important, often combined with Doppler investigation and much more rarely with phlebography. The treatment of this perforator is essentially medical, by sclerosing injections, and sometimes surgical, after indications have been carefully weighed. New methods of treatment, such as the CHIVA technique, are also being developed but there is an insufficient follow-up time to enable any objective conclusion to be drawn.     

The role of Apligraf in the treatment of venous leg ulcers

A cultured, allogeneic, bi-layered human skin equivalent has recently become available to help clinicians manage difficult-to-heal venous ulcers. This skin equivalent has an epidermis and dermis similar to human skin. Its living keratinocytes and fibroblasts are from cultured cell banks derived from human neonatal foreskin. Because the skin equivalent is made up of viable human cells, it cannot be terminally sterilized. Safety concerns, which have been addressed, include the risk of possible transmission of infection, immunogenicity, immunological graft rejection, and tumor formation. However, the maternal blood of the neonatal donor and the master cell banks are screened for infectious agents. Additionally, the human skin equivalent is produced under strict aseptic control, with sterility continuously monitored by the Good Manufacturing Processes. This paper reviews the characteristics of this human skin equivalent and provides practice guidelines.     

The role of medical treatment of distal type aortic dissection

We analyzed the short-term and long-term outcome of 42 patients with distal type aortic dissection. Twenty-eight patients underwent intensive medical therapy within two weeks after the onset of pain (acute dissection). The remaining 14 patients had chronic dissection. The goals of medical treatment were to control blood pressure and to attain a negative C-reactive protein test result. Hospital survival rate in the patients with acute dissection was 96% (27/28). In-hospital complications included changes in mental status, renal dysfunction, bradycardia, orthostatic hypotension, and liver dysfunction, all of which were managed medically. Three of these patients underwent surgical therapy in the chronic phase and were discharged uneventfully. Fifteen (62.5%) of the 24 medically treated patients were discharged with negative C-reactive protein tests. Spontaneous resolution of a dissection was demonstrated by radiological examinations in 8 cases. Five-year survival rates in 24 medically treated patients was 93%. Hospital survival rate in the patients with chronic dissection was 100% (14/14). The rigorous control of blood pressure in the acute phase, and subsequent meticulous evaluation of the dissection by radiological tests and C-reactive protein test provides acceptable short-term and long-term outcomes of patients with acute distal dissection without the need for emergency surgical intervention.     

The role of low-molecular-weight heparins in the prevention and treatment of venous thromboembolism in cancer patients

Accumulating evidence suggests that low-molecular-weight heparins are the drug of choice for the prevention and treatment of venous thromboembolism in patients with cancer. For prophylaxis in the surgical setting, once-daily subcutaneous injections of low-molecular-weight heparin are as effective and safe as multiple doses of unfractionated heparin. Extending prophylaxis with low-molecular-weight heparins beyond hospitalization was recently found to reduce safely the risk of postoperative thrombosis after abdominal surgery for cancer. For the long-term treatment of deep vein thrombosis and in select patients with pulmonary embolism, recently completed clinical trials have shown that secondary prophylaxis with low-molecular-weight heparin is feasible and more effective than oral anticoagulant therapy in preventing recurrent venous thromboembolism in cancer patients. There is also evidence that low-molecular-weight heparins are effective in cancer patients who develop recurrent thrombosis while on warfarin therapy. Lastly, the potential antineoplastic effects of low-molecular-weight heparins make these agents an attractive option in patients with cancer. Although the management of cancer patients with venous thromboembolism remains challenging, low-molecular-weight heparins have simplified and improved the prevention and treatment of venous thromboembolism in these high-risk patients.     

The rationale and evidence for the treatment of lower-extremity deep venous thrombosis with thrombolytic agents

This article presents the rationale and evidence for the treatment of lower-extremity deep venous thrombosis (DVT) with thrombolytic agents. DVT is a common condition that has both acute and chronic complications. Standard treatment including anticoagulation therapy and compression stockings may not be entirely adequate, because a significant proportion of patients eventually develop severe post-thrombotic syndrome (PTS). Thrombolytic agents offer a potential advantage because they may reduce residual vein stenosis and valve damage. The authors performed a systematic review of published randomized trials evaluating thrombolytic agents for DVT. The authors determined that thrombolysis therapy results in greater lysis and complication rates than does anticoagulation alone. The authors also found that PTS incidence is lower in patients treated with thrombolytics. However, several methodological flaws limit the conclusions with respect to reduction in PTS. Therefore, the authors conclude that although the lysis rate is greater for thrombolytic agents, they cannot be recommended routinely for DVT treatment.     

Surgery of the perforating veins in chronic venous diseases of the lower limbs

After a brief anatomical reminder, the author discusses the place of surgery of the perforating veins in chronic venous deficiency, in three distinct aetiological and clinical circumstances: A first-hand prospective study of 220 successive operations for primary varices is analysed. In 14.5% of the cases, ligation of the perforators was associated with the stripping. In a retrospective analysis relating to 100 surgical reoperations on primary varices, the ligation of the perforators was associated with a different procedure in 13 of these patients. Finally, the author specifies the place of surgery of the perforators in the treatment of post-phlebitic syndrome. As regards the relapsing ulcer, 81% of the patients who had benefitted from this procedure never suffered relapsed ulcers (27 patients).     

Postural obstruction of the popliteal vein. Its role in deep venous insufficiency of the legs]

Postural or, more generally, positional obstruction of the popliteal vein occurs either in complete extension of the leg, or in powerful flexion of the order of 90 degrees. It is sometimes constitutional and sometimes acquired, as a result of dystrophy of the venous wall. Abnormal phlebographic appearances vary according to the position of the leg and the level of the obstruction: signs of narrowing or axis displacement with the knee in extension; plications, sinuousities, stenosis, curved imprints with the knee in flexion. The actual existence of circulatory slowing has been confirmed by Doppler. Hemodynamic consequences appear to be all the more severe when the obstruction is tighter, situated higher and when the great saphenous itself is narrowed at the level of the popliteal crease. Despite its intermittent nature, positional obstruction must be kept under consideration: in hospital medicine, because of the potential danger of venous stasis which it causes, with the risk of underlying thrombosis; in everyday phlebology, since it explains, to a certain extent, the mechanisms of chronic venous insufficiency occurring after standing upright or sitting for prolonged periods. Awareness of this possibility forms the basis of a number of general rules concerning good venous health, certainly by no means original but rarely observed.     

Interleukin 8 and venous thrombosis: evidence for a role of inflammation in thrombosis

Elevated plasma levels of interleukin 8 (IL-8) were previously shown to be associated with recurrent venous thrombosis. To assess the risk of venous thrombosis, IL-8 plasma concentrations were measured in patients and control subjects of the Leiden Thrombophilia Study (LETS). This population based case-control study included 474 patients with a first deep-vein thrombosis and 474 age- and sex-matched controls. The risk of venous thrombosis for subjects with elevated IL-8 levels (above 90th percentile of controls) compared with subjects with IL-8 levels below the 90th percentile was increased 1.8-fold (95%CI 1.2-2.8). Adjusted for age and sex, the odds ratio was 1.9 (95%CI 1.3-2.8). IL-8 concentrations were weakly correlated with age, male sex, and concentrations of C-reactive protein, factor VIII coagulation activity and homocysteine, but adjustment for these factors did not substantially affect the association between IL-8 and venous thrombosis. Our results suggest that IL-8 is a risk factor for venous thrombosis.