Phlebology: The Journal of Venous Disease

To assess the long-term results of re-do surgery for recurrent varicose veins using polytetrafluoroethylene patch interposition to correct a recurrent varico-femoral junction (RVFJ).

In 170 extremities (137 patients) with RVFJ greater than 3 mm in diameter, re-do surgery was done with patch interposition and without extensive resection of neovascularisation. Follow-up data based on physical and ultrasound examinations were obtained for 119 of these extremities (100 patients).

Private-practice vascular surgery centre.

At follow-up (mean 4.9 years), 5 extremities (4.2%) had another RVFJ. In the 114 extremities with no RVFJ, 27.7% had no varicose veins or incompetent superficial veins, 45.3% had several small varicose veins without reflux, and 22.6% had diffused varicose veins and a new site of incompetence between the deep and superficial venous system.

Re-do surgery using patch interposition lowers the long-term risk of another RVFJ. Wide resection of neovascularisation in the groin seems unnecessary.

To evaluate the outcome of re-operation in the groin for recurrent varicose veins.

Retropective follow-up study

Department of Vascular Surgery, Gentofte University Hospital, Copenhagen, Denmark.

Thirty-two patients with 43 operated legs. Operations were performed between January 1996 and the end of April 1997 and solely as a groin dissection; no stripping was done. Follow-up consisted of a clinical examination and duplex scanning with an ATL HDI 5000 scanner.

Sixteen cured legs, 17 with reflux beginning at mid-thigh, mainly a Hunter's perforating vein, and 10 with remaining reflux at the sapheno-femoral junction.

Recurrence rate in the groin is acceptable. Stripping of the long saphenous vein is mandatory to bring down the recurrence rate from mid-thigh perforating veins. This is now standard procedure in our department.

To determine the site-specific rates of recurrence following varicose vein surgery.

Postal questionnaire followed up by telephone enquiries. Full clinical review, including continuous wave and duplex Doppler investigations were carried out for all patients with responses suggesting recurrence.

Surgicare Manchester, an independent provider of specialist varicose vein treatments. All procedures were guided by Doppler ultrasound and performed by surgeons working to the same protocol.

A consecutive series of 250 operations on 246 Patients. Of these, 208 (85%) could be contacted for follow-up. Mean time to re-examination was 27 months.

Twelve patients returned spontaneously and 51 were recalled for examination based on questionnaire responses. Recurrences were divided into ‘site’, ‘perforator’ or ‘new site’ recurrence. Primary surgery to the sapheno-femoral junction (SFJ) had the lowest ‘site’ recurrence rate of 2.3% compared with 9.5% for SFJ re-operation. Primary surgery and re-operation of the sapheno-popliteal junction (SPJ) had higher recurrence rates of 8.3% and 7.8% respectively. New incompetence was detected in 5% and 2% of previously competent SFJ and SPJ respectively. Minor perforator incompetence was found in a further 14%.

Varicose veins were progressive in some individuals, with new sites of incompetence appearing over time. However, ‘cure’ remains possible for most Patients and major recurrence can be reduced by Doppler diagnosis and precise surgery.

To evaluate the difference between competent valves and incompetent valves with regards to the development of expression of cytokines and adhesion molecules in primary varicose veins.

Specimens were obtained from 13 patients with primary varicose veins during surgery. Valves were classified according to the angioscopic findings: 8 competent and 17 incompetent valves; type I (7 valves with elongated cusps) and type II (10 valves with expansion of commissures). The mRNA levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), tumour necrosis factor-α (TNF-α), transforming growth factor-β (TGF-β), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and endothelial leucocyte adhesion molecule-1 (ELAM-1) were measured by polymerase chain reaction (PCR) amplification of cDNA reverse-transcribed from RNAs.

In all cases there were few appearances of IL-6, IL-8 and TNF-α at the valve cusps. TGF-β and VCAM-1 levels were highly elevated in the cusps of incompetent valves compared with competent valves (p<0.05). At the venous wall IL-6 and IL-8 occurred more frequently in incompetent valves than in competent valves (p<0.05).

This study suggests that inflammatory cytokines and adhesions molecules, especially TGF-β, IL-6, IL-8 and VCAM-1, may be related to the occurrence of valve insufficiency.

Ultrasonography of the anatomical course of the long saphenous vein (LSV) and its tributaries to produce and verify an anatomical classification (five types).

Four hundred and ninety-three limbs (293 healthy; 200 with varicose veins, VV) were investigated by ultrasonic duplex imaging by the two authors independently, identifying the LSV as the vessel in the (ultrasonic) saphenous fascial ‘eye’ compartment (SFEC), in the thigh, and within two fascial layers between tibia and medial gastrocnemius muscle, below the knee.

Type A: LSV runs entirely in the SFEC without relevant tributaries: overall (O) 112 (23%), limbs with vv (V) 13, normal limbs (N) 99. Type B: LSV runs in the SFEC with one or more relevant tributaries below the knee: O 133 (27%), V 70, N 63. Type C: LSV runs in the SFEC with a relevant tributary above the knee: O 89 (18%), V 28, N 61. Type D: LSV runs in the SFEC from the foot upwards, continuing at the middle third of the leg in a large side vein with the calibre and role of the LSV but in a more superficial location. LSV stem is absent (or hypoplasic) in the para-tibial position. At the thigh level the tributary re-enters the true LSV: O 72 (14.5%), V 42, N 30. type E: similar to type D but the LSV is absent only at the knee level: O 72 (14.5%), V 38, N 34. Unclassified: O 15 (3%), V 9, N 6.

We found a good reproducibility and clinical utility of the suggested classification. Remarks: (a) the absence (or hypoplasia) of LSV at the knee level with prevalence of a tributary in almost 30% of the limbs is of importance for arterial bypass and saphenous sparing management; (b) there is a low rate of LSV complete incompetence (6%); (c) there is a correlation between absent LSV (or presence of a relevant tributary) and the incidence of VV.

To evaluate the effect of compression hosiery during standing work.

An open study, comparing symptoms and plethysmographic findings before and after treatment.

University hospital, vascular surgery.

Forty-eight female volunteers with a standing profession.

Visual analogue scale to evaluate symptoms and foot volumetry to study venous function before and after 4 weeks use of compression hosiery (20–30 mmHg).

All scores for symptoms were significantly reduced after treatment. Only 21% of the study subjects had minor abnormalities on foot volumetry. The expelled volume was significantly higher after work at 4 weeks than at the first measurement at inclusion, while the refilling rate was significantly lower after work at 4 weeks than at the corresponding measurement at inclusion.

Symptomatic improvement was recorded after compression treatment. Limited effects were seen with the objective measurement, although the most important factor, the refilling rate, diminished significantly during the treatment period. Compression treatment reduces lower limb symptoms following standing work.

To assess the impact on deep vein thrombosis (DVT) protocol violations of the introduction of a label attached to the patient's drug chart, which specifically allows low-dose subcutaneous heparin or thromboembolic deterrent stockings (TEDS) to be prescribed as appropriate.

An audit study.

Department of General Surgery of a District General Hospital in the United Kingdom.

All adult general surgical inpatients on a Weekday were studied. Staff were not forewarned of the studies. Patient details and risk factors for DVT were noted. Details of administered DVT prophylaxis were recorded. In total four separate studies were undertaken, namely: with original protocols (I), with refined protocol 1 and 3 years later (II, III) and finally after introduction of the label (IV).

Protocol violations were defined as being ‘acceptable’ or ‘unacceptable’. Raising awareness between studies I and II reduced acceptable violations to zero. There was no statistically significant reduction in unacceptable violations (24 in 80 patients, 1; 17 in 75, II; 13 in 60, III). In study IV, following introduction of the label, there were only 6 violations in 51 patients (p<0.02).

Combining increased awareness with the attachment of a label to the drug chart reduced unacceptable violations by 63%.

Case report.

Department of Otolaryngology and Head and Neck Surgery, St. John's Medical College Hospital, India.

A 22-year-old man with a cord-like neck mass of 6 months' duration.

Investigations included Doppler ultrasound of the neck, which showed thrombosis of the right external jugular vein. Wedge biopsy revealed a granulomatous inflammation with focal necrosis completely replacing the vessel. Serological testing for vasculitides was negative. Transcervical excision of the vein was carried out after identifying normal vessel distally and proximally. Histopathological examination of the vein proved the lesion consistent with primary cutaneous granulomatous phlebitis (PCGP).

Isolated venous inflammatory diseases with neither identifiable active vasculitis nor arteritis are rarely seen. PCGP is distinctly unusual. We report a case of PCGP of the external jugular vein presenting as an elongated cord-like nodular lesion in the lateral neck of insidious onset.