MANAGEMENT OF CONGENITAL ANGIODYSPLASIA OF THE LOWER LIMB: MAGNETIC RESONANCE IMAGING AND ANGIOGRAPHY VERSUS CONVENTIONAL ANGIOGRAPHY
 Huch B–ni RA, Brunner U, Bollinger A, et al.
Br J Radiology 1995; 68:1308-15

ABSTRACT AND COMMENTARY BY:
Robert B. Rutherford, M.D.
Professor of Surgery, Vascular Surgery
University of Colorado Health Sciences Center
Denver, Colorado

The authors compared magnetic resonance imaging and angiography versus conventional angiography in 13 patients, 4 of whom had purely venous lesions and 9 of whom had microfistulous AV malformations. MRI was found to be the best study for determining the anatomic extent of the vascular malformation and the involvement of underlying anatomic structures. MR arteriography and MR venography were inferior to conventional techniques in providing sufficient detail for interventional planning. MR arteriography often failed to demonstrate the extent of the lesion and, although all large feeding arteries were readily seen, the anatomy of the vessels feeding the nidus of AVMs was adequately demonstrated in one of 9 patients. MR venography identified all superficial venous pathology except for one dysplastic greater saphenous vein but the pathology was properly identified in only 5 of the 8 cases.

COMMENTARY

The authors' conclusions are in concert with the advice now offered in standard vascular surgical texts1 and the conclusions of earlier experiences with MRI reported by Pearce2 and Cohen3 and their colleagues. This reviewer's approach incorporates the value of MRIs but starts with simpler noninvasive testing.

First, noninvasive arterial studies (particularly arterial velocity, flow rates, and waveform analysis) are used to rule out or rule in AV shunting. These studies allow gross evaluation of the degree of AV shunting although this is better quantified with labeled albumin microsphere studies.4 Duplex scanning is also used to study the purer venous malformations, to screen for involvement of the axial veins (dysplasia, hyperplasia, aplasia) and to demonstrate the presence of marginal or embryonal veins. Duplex is also useful for interrogating venous masses to confirm that they are extratruncular and not associated with high flows as in cases with associated microfistulous AVMs. These studies are all done at the time of initial clinical evaluation in a nearby vascular diagnostic laboratory which allows one to make appropriate clinical decisions, in most cases, at the time of the initial visit.

MRI is reserved mainly for mass lesions or lesions which appear to be localized enough to justify the consideration of intervention for cure. It is indeed very effective in demonstrating anatomic extent and involvement of the deep structures (e.g. bone, joint, muscle) and often will determine that "radical cure" is not feasible. This allows conventional angiography to be reserved for those patients in whom intervention is needed either for palliation and control of the secondary hemodynamic efforts or in those who may be potentially cured by such intervention.

There is still much confusion about which cases can be "cured" and whether the "cure" is worth it. At the moment, the appropriateness of multiple sessions of sclerotherapy with ethanol for rather benign extratruncular venous lesions is debatable and probably not cost effective. However, the same approach appears to be quite valuable in macrofistulous AVMs when the agent can be delivered into the nidus of the lesion. Microfistulous AVMs are often diffuse and hard to get at but their hemodynamic consequences are also much less. "Radical cure," to use the authors' term, would seem limited to 5 to 10% of congenital vascular malformations. Thus, it would be appropriate to subject all patients to routine angiography as has been done in the past.

Simpler noninvasive studies supplemented by MRI in selected individuals allows most patients to be appropriately evaluated and screened for possible intervention. This approach is also cost effective. 5838b

REFERENCES

1. Anderson BO, Durham JD, Rutherford RB. Congenital malformations of the extremities. In: Moore WS (Ed). Vascular Surgery: A Comprehensive Review, 4th Ed. WB Saunders Co., Philadelphia 1993; pp 160-70.

2. Pearce WH, Rutherford RB, Whitehill TA, Davis K. Nuclear magnetic resonance imaging: Its diagnostic value in patients with congenital vascular malformations of the limbs. J Vasc Surg 1988; 8:64-70.

3. Cohen JM, Weinreb JC, Redman HC. Arteriovenous malformations of the extremities: MR imaging. Radiology 1986; 158:475-79.

4. Sumner DS, Rutherford RB: Diagnostic evaluation of arteriovenous fistulas: Radionucleide assessment. In: Rutherford RB (ed). Vascular Surgery, 3rd ed . WB Saunders Co., Philadelphia, 1989; pp 1037-38.




ANGIOSCOPY-ASSISTED VALVULOPLASTY FOR PRIMARY DEEP VENOUS VALVULAR INSUFFICIENCY
 Lermusiaux P, De Forges MR
Ann Vasc Surg 1996; 10:233-38

ABSTRACT AND COMMENTARY BY:
Harold J. Welch, M.D.
Associate Professor of Surgery
New England Medical Center
Boston, Massachusetts

The authors describe their experience with angioscopy assisted valvuloplasty in four patients with venous ulceration from one to over ten years. All four had previously undergone stripping of the greater saphenous vein and two also had undergone ligation of incompetent perforating veins. Preoperatively, the patients underwent ascending and descending phlebography as well as venous pressure measurements.

A 2.3 mm. angioscope was inserted through a collateral of the greater saphenous vein or via a short 9-French intraducer in the common femoral vein. Under angioscopic guidance, the valve commissures were narrowed, and the cusps reefed with interrupted 7-0 Prolene sutures. The repair was then assessed through the angioscope. In one patient, two valves were repaired by initially passing the angioscope past an incompetent valve to repair the downstream valve. All patients had the valvuloplasty wrapped with PTFE and were kept on Coumadin for six months. Postoperatively, there were no complications. At a mean followup of 12 months, there was no thrombosis by duplex or ascending phlebography. Descending phlebography showed competency of the repaired valves. Three of the four patients healed their ulcers and the fourth showed significant improvement. Ambulatory venous pressures were improved postoperatively in two patients, and filling times were improved in all four patients.

COMMENTARY

The authors describe a technique that has been previously reported by Gloviczki, et al.1 and our group.2 Closed valvuloplasty with or without angioscopic assistance is becoming the preferred method of valve repair. The authors duly noted the discrepancy in clinical results and hemodynamic improvement with correction of venous reflux. The long-term healing of chronic venous ulceration is the ultimate goal of these procedures. This study and others have nicely shown that these goals can be achieved with minimal postoperative morbidity. 5839b

REFERENCES

1. Gloviczki P, Merrell SW, Bower TC. Femoral vein valve repair under direct vision without venotomy: A modified technique with use of angioscopy. J Vasc Surg 1991; 14:645-48.

2. Welch HJ, McLaughlin RL, O'Donnell TF Jr. Femoral vein valvuloplasty: Intraoperative angioscopic evaluation and hemodynamic improvement. J Vasc Surg 1992; 16:694-700.




VENOUS THROMBOEMBOLIC DISEASE IN OBSTETRICS AND GYNECOLOGY: THE SCOTTISH EXPERIENCE
 Macklon NS, Greer IA
Scot Med J 1996; 41:83-86

ABSTRACT AND COMMENTARY BY:
Richard E. Blackwell, Ph.D., M.D.
Professor of Obstetrics and Gynecology
Division of Reproductive Biology/Endocrinology
University of Alabama at Birmingham
Birmingham, Alabama

This retrospective manuscript from the Glasgow Royal Infirmary in Scotland evaluates the recorded thromboembolic complications in obstetrics and gynecologic practice in Scotland from 1981 through 1992, provided by the Information of Statistics Division of the Common Services Agency for the National Health Service. Information was extracted from SMR1 database gynecology and SMR2 database obstetrics.

A total of 800,000 gynecological admissions and over 700,000 maternities were analyzed by ICD-9 codes. In gynecology, pulmonary embolism, phlebitis, thrombophlebitis, and other venous emboli and thrombosis were evaluated. Admissions to the gynecology services 1 to 14 days after and 15 to 60 days after an initial episode were evaluated as were admissions to the medical/surgical services or other specialties during the same time period. Obstetrical cases were evaluated based on the diagnosis of superficial thrombophlebitis, antepartum deep venous thrombosis (DVT), postpartum DVT, and pulmonary embolism (PE). Variables analyzed included mode of delivery and age. The obstetrical data was analyzed using chi-squared tests for statistical significance between rates of thrombotic events per 10,000 deliveries.

From 1981 to 1991, there were 745,999 new episodes in gynecology. A total of 27,308 readmissions occurred within the first 14 days and 33,123 between days 15 and 60. These figures indicate an overall readmission rate of 10.25% with 85% occurring in the first 14 days. Over the 11-year period, 574 admissions were associated with thromboembolic complications (0.076% of new gynecologic episodes). Of these, 297 occurred during the first admission, and 0.11% of the readmissions to gynecology were for thromboembolic complications. A total of 35% (n = 22) of those readmitted to gynecology were diagnosed with PE. Ten percent of those admitted to medical/surgical specialties carried a similar diagnosis.

From 1983 to 1992, there were 645,663 maternities with 44,410 women over age 35 (6.88%). It should be noted that the proportion of maternities in women over age 35 rose significantly during the study period from 6.25% in 1983 to 8.5% in 1992. Over a ten-year period, 89,618 cesarean sections were performed (13.88%). Cesarean section in women over age 35 was increased (20.77%) compared to those under age 35 (13.37%). Cesarean sections were performed as an elective procedure in 37.7%, and this figure rose to 47.87% in group over age 35. The overall incidence of antenatal DVT was 0.65/1,000 maternities under age 35. The incidence was 1.62/1,000 maternities over age 35 which is significant. A similar effect was seen with postnatal DVT with a rate of 0.304/1,000 maternities under age 35 and 0.72/1,000 over age 35. Again, this is significant. Patients over age 35 also had a significantly higher rate of PE than those under 35. Likewise, a similar age-related increase was observed in superficial thrombosis.

The incidence of postnatal DVT was markedly affected by the mode of delivery. Cesarean section was associated with a rate of 0.42/1,000 compared with a rate of 0.173/1,000 following vaginal birth. Emergency C-sections were associated with a higher rate of postnatal DVT than elective sections under age 35 (0.431/1,000 versus 0.238/1,000) and in those over age 35 (1.248/1,000 versus 0.680/1,000). C-section delivery was associated with a higher incidence of pulmonary thromboembolism than vaginal delivery in all age groups. A significantly higher incidence was found to be associated with emergency versus elective C-section in the over-35 group.

The authors conclude: "Despite changes in modern practice, thromboembolic disease remains an important cause of maternal mortality and morbidity. Its importance in gynecological practice may have been underestimated. The application of data from studies such as this may help us to improve the identification of those at risk and institute appropriate preventive measures."

COMMENTARY

The authors point out that many obstetricians and gynecologists do not prescribe thromboprophylaxis to their patients because of their perceived low incidence of thromboembolic disease in their practice. While it is true that most gynecologists in the United States do not prescribe medical prophylaxis in patients undergoing gynecologic surgery, there has been a religious use of pneumatic leggings and rapid ambulation postoperatively for many years. Further, the move to outpatient surgery that began in the early 1990s and the advent of managed health care in the United States has accelerated early discharge and ambulation within an hour postoperatively. The authors state that the overall 10% readmission rate following an initial gynecologic episode is a matter of concern, and I agree. These figures do not seem to be compatible with the experience of gynecologists in the United States, and are certainly not reflective of our experience at the University of Alabama at Birmingham (UAB).

The figure of 13.9% C-section rate in Scotland deserves comment. The overall figures in the United States show a C-section rate of about 23% in 1993. The experience with the UAB high-risk perinatal service is 18%. This reflects the enthusiasm for vaginal birth after cesarean section (VBAC) practiced at UAB with approximately 80% of women who have undergone a single low-transverse C-section delivering vaginally. The incidence of DVT and pulmonary thromboembolism in our postpartum group is less than one per thousand. The admirable C-section rate demonstrated by the Scottish experience is the result of numerous factors, including the character of Scottish women, the legal environment, and the use of midwives. As indicated by the database, control of the C-section rate would certainly allow for control of one risk factor for the development of embolic disorders. 5840b




BLUNT BRAIN INJURY ACTIVATES THE COAGULATION PROCESS
 Hulka F, Mullins RJ, Frank EH
Arch Surg 1996; 131:923-28

ABSTRACT AND COMMENTARY BY:
John J. Bergan, M.D., FACS
Professor of Surgery
Loma Linda University Medical Center
Clinical Professor of Surgery
University of California, San Diego
Uniformed Services Univ. of the Health Sciences

This article from the Department of Surgery and Divisions of Trauma and Neurosurgery of the Oregon Health Sciences University presents important information. The objective of the study was to measure the prevalence of coagulopathy in patients with blunt brain injury, based on a retrospective study of patient charts.

One hundred fifty nine (159) patients with evidence of blunt head trauma who had computed tomography of the brain during their initial evaluation were examined. A coagulopathy score was assigned which was based on platelet count, prothrombin time, partial thromboplastin time, fibrinogen level, and D-dimer level. A disseminated intravascular coagulation score ranging from 0 to 15 was utilized in the evaluation. Of the 91 patients with brain injury, 41% had coagulopathy with an intravascular coagulation score greater than 5. These were compared to 68 patients without brain injury, only 25% of which had coagulopathy. The patients with brain injury who developed profound depletion of fibrinogen did so within four hours of injury. Ultimately, there were 28 deaths, 26 of which were in the group with brain injury and two in the group without. Among the patients with brain injury, those with coagulopathy died more frequently. Also, patients with brain injury and coagulopathy deteriorated more frequently as based on the computed tomography criteria.

The authors conclude that after blunt brain injury, disseminated intravascular coagulation can lead to consumptive coagulopathy which is associated with a higher frequency of death. This syndrome develops within one to four hours after injury and therapeutic interventions need to be implemented immediately if they are to be effective.

COMMENTARY

Although the focus of this presentation is on trauma patients, it should be realized that patients with extensive radiotherapy to the brain may also present with coagulopathy. The mechanism for the coagulopathy is probably tissue thromboplastins released from the damaged brain which enter the circulation, activate the extrinsic coagulation pathway, and produce fibrin clot. In worst cases, activation of the clotting cascade can be massive, fibrinogen critically depleted, with hemostasis failure ensuing. It is generally agreed that the magnitude of intravascular coagulation is proportional to the amount of brain tissue which is disrupted.

This presentation points out that the disseminated intravascular coagulation process after brain injury has a wide range of manifestations rather than merely being present or absent. This study does not comment on the consequences of coagulopathy such as pulmonary embolization nor does it draw attention to the fact that in patients with such a coagulopathy, placement of a vena cava filter may allow thrombosis of the filter site and progression of thrombus above the filter. 5608b




PIN STRIPPING (Publication in German)
 Oesch A.
Phlebologie 1996; 25:177-82

ABSTRACT AND COMMENTARY BY:
Dr. med. Reinhard H. Fischer
St. Gallen, Switzerland

PIN stripping means Perforation INvagination stripping. The PIN stripper is a semiflexible, stainless steel rod less than 2 mm. in diameter. For the greater saphenous vein, it is 52 cm. long, and for the lesser saphenous vein, it is 30 cm. long. At the distal tip, it is bent upward like a ski for easy palpation through the skin and for perforation of the vein being removed. At the other end which is used for manipulation, the stripper is flattened and slightly bent. This is designed to be held between the thumb and the index finger. The working end presents a perforation which can be used for the ligature.

The PIN stripper is designed to be introduced into the vein being removed from the site of proximal ligation down to the intended level of resection. At this point, the angulated tip is directed toward the skin by rotating the proximal end of the stripper appropriately. Downward pressure on the stripper and with the angulated end pointed toward the skin, the vein is perforated and a 3 to 5 mm. incision is made over the tip of the stripper (Fig.1). The stripper end is grasped with a small forceps and extracted so that the proximal end of the stripper will be adjacent to the proximal end of the vein being removed. A strong tie is introduced through the perforation in the stripper and knotted on the vein tip (Fig.2). Thereafter, the stripper is removed in a distal direction and the proximal end of the vein invaginates into itself and the vein is removed inside out through the distal incision.

The chief advantages of PIN stripping are the small distal incisions and the possibility that adjacent saphenous and sural nerves will be less damaged. Clearly, the distal incision is so small that the vein is not dissected free of the nerve which is particularly important for the lesser saphenous vein and the sural nerve. Also, because of the small diameter, PIN stripping is less invasive than conventional stripping.

Oesch reports 609 cases with no nerve injury noted. In 50 cases, the stem vein being removed was torn and required removal by the stab avulsion technique using hooks. In a small number of cases, the proximal end of the stem vein was not firmly tied and became disconnected.1



COMMENTARY

Oesch has improved the method of PIN stripping over that first published in 1993 in the United States.2 The technique is particularly valuable for use on the lesser saphenous vein because the sural nerve lies subfascially and particularly close to the vein in the distal third of the leg. When used for the greater saphenous vein, the patient's abdomen may interfere with manipulation of the proximal end of the stripper. Oesch removes any torn, residual vein with hooks. However, there are alternative ways to do this, including introduction of a conventional stripper using a tie which is left in the stripper canal. Many phlebologists confirm that PIN stripping reduces nerve lesions. However, few can equal Oesch's zero rate of nerve injury.

The PIN stripping technique presents an important forward step in vein surgery. I expect it to find widespread use because of its reduction of nerve injuries, the small incisions, and the general, minimally invasive nature of the procedure. 5696b

REFERENCES

1. Oesch A. PIN stripping: A novel method of atraumatic stripping. Phlebology 1993; 8:171-73.

2. Goren G, Yellin A. Minimally invasive surgery of primary varicose veins. Limited invaginated stripping and tributary (hook) stab avulsion. Ann Vasc Surg 1995; 9(4):401-14.




A 47-YEAR-OLD WOMAN WITH A SWOLLEN LEG
 Longworth DL, Stoller JK
Clev Clin J Med 1995;62:281-84

ABSTRACT AND COMMENTARY BY:
Travis J. Phifer, M.D.
Associate Professor of Surgery
Chief, Division of Vascular Surgery
School of Medicine in Shreveport
Shreveport, Louisiana

This article, written in the format of a review for Board exams, addresses diagnosis and treatment of a popliteal cyst caused by Borrelia infection (Lyme disease) presenting as unilateral calf swelling with a tender popliteal fossa "mass." The differential diagnosis discussed in the article includes deep venous thrombosis, popliteal aneurysm, popliteal cyst, muscular tear or rupture (gastrocnemius, plantaris, soleus), infectious processes (necrotizing fasciitis, cellulitis), hematoma formation, various neoplasms, and excess fat.

Since deep venous thrombosis coexists with a popliteal cyst in one-third of such cases, the authors also recommend examination of the venous system after diagnosis of a popliteal cyst. Duplex ultrasonography is particularly important as a diagnostic modality for this problem, with sensitivity of about 70% for 1 to 2 cm. popliteal cysts and greater than 90% for deep venous thrombosis. Arthrography and magnetic resonance imaging are useful for more complex problems, including smaller cysts and meniscus disease.

Etiologic possibilities for a popliteal (Baker's) cyst are the same as for acute monarticular (knee) synovitis and include, as delineated in the article, both inflammatory and non-inflammatory causes. However, rheumatoid arthritis and osteoarthritis, as well as meniscal tears account for almost 95% of all popliteal cysts. These cysts often coexist with conditions characterized by recurrent or persistent knee effusion, and most frequently result from accumulation of synovial fluid in the gastrocnemic semimembranosus bursa communicating with the knee joint as an extension of the posteromedial capsule. Precise resolution of the question of etiology requires, as with all monarticular arthritis, synovial fluid analysis focused on white cell count and the presence or absence of crystals as well as appropriate tests for infection. Determination of the exact cause of a popliteal cyst is of paramount importance in planning therapy.

Although autopsy slides show popliteal cysts in up to 50% of the general population, such cysts are usually small and asymptomatic. Popliteal cysts associated with an acute knee injury and an effusion often resolve after either spontaneous resolution of the effusion or after removal of the fluid by arthrocentesis. However, untreated and chronic effusions potentiate symptomatic popliteal cyst formation with subsequent enlargement and distal dissection. Rupture of a cyst sometimes causes a pseudothrombophlebitic syndrome with ecchymosis below the malleolus (the "crescent sign") consequent to blunt dissection of blood down fascial planes. Such bleeding poses a possible, though uncommon, danger of treating presumed deep venous thrombosis with anticoagulants in the absence of documented venous thrombosis.

For inflammatory but non-infected cysts, general treatment measures include limitation of activity as well as nonsteroidal antiinflammatory medications and/or intraarticular steroid injections. Any intraarticular mechanical problem such as loose cartilaginous bodies or meniscal flaps require arthroscopic correction. Treatment of infectious cysts (commonly Gonococcal, Staphylococcal, and Streptococcal; uncommonly more indolent process such as lyme arthritis and fungal arthritis) includes possible drainage as well as appropriate systemic antibiotic therapy. Surgical excision of a popliteal cyst without investigation of its underlying etiology is often inadequate and associated with cyst recurrence. In contrast, treatment of underlying conditions sometimes results in resorption of the cyst without further cyst enlargement or dissection.

COMMENTARY

This is an interesting discussion of a case of popliteal cyst caused by Borrelia infection presenting as a swollen leg. Written as a review for Board exams in internal medicine, the question-and-answer format is engaging as the reader works through diagnosis and treatment of the problem. Although etiology of the cyst in the case presented is unusual, the entity of popliteal cyst itself is common enough for serious consideration in the differential diagnosis in most cases of leg swelling. Also, concomitant occurrence of popliteal cyst and deep venous thrombosis in at least one-third of cases of popliteal cyst emphasizes the importance of accurate diagnosis.

The differential diagnosis as well as diagnostic methods and treatment protocols presented are reasonably standard and provide a good review but basically no new information. The major value of the article is that it is a reminder of the complexity of the rather common problem of the swollen leg. Tunnel vision with inaccurate diagnosis and incomplete treatment potentiates not only delayed resolution of the problem but also increased morbidity. 5395b




MINI ABSTRACTS
John J. Bergan, M.D.
Items of Interest Which Have Crossed the Editor's Desk
(Provided for reference purposes and general interest)


Neovascularization in Recurrent Saphenofemoral Incompetence of Varicose Veins: Surgical Anatomy and Morphology
Glass GM
Phlebology 1995; 10:136-42

The author of this article has a long interest in uncovering the cause of varicose vein recurrence after surgery. For this report, 141 limbs were examined four or more years after treatment by saphenofemoral ligation, and ligation of varicose tributaries and communicating veins. This study shows that the surgical anatomy of the recurrent system of veins developing after ligation is different from the pattern after stripping. Recurrence was thought to be through newly formed vessels which became continuous with the greater saphenous vein. If the saphenous vein is left in situ, the communications go directly to this vessel, and if the saphenous vein is absent, distal continuity is established with normal superficial veins which subsequently become dilated and incompetent.