ILIAC VEIN COMPRESSION SYNDROME: CASE REPORT AND REVIEW OF THE LITERATURE
 Akers DL, Creado B, Hewitt MD
J Vasc Surg 1996; 24(3):477-81

ABSTRACT AND COMMENTARY BY:
Morris D. Kerstein, M.D.
Professor of Surgery
Allegheny University of the Health Sciences
Philadelphia, Pennsylvania

This article addresses common anatomy (the left iliac vein is posterior to the right iliac artery) that may help explain why symptoms and sequelae of venous disease (edema, pain, varicosities, stasis changes, venous ulceration, venous claudication) may be more common on the left lower extremity than on the right and more common in women (85% in one series) in the second to fourth decade of life.

The authors present a 16-year-old man with recurrent cellulitis, documented venous stasis, and a venous gradient on either side of the crossing left iliac vein below the right iliac artery who did not resolve his symptoms and pathology with antibiotics and anticoagulation. Transposition of the right iliac artery behind and below the left iliac vein in addition to six months of anticoagulation resolved the problem.

COMMENTARY

The authors describe a problem that may be more common than we realize but not necessarily requiring the same aggressive interventional surgery. They correctly observe that venous problems may be more common in the left than the right lower extremity. A very small subgroup may benefit by arterial transposition after appropriate conservative treatment has been unsuccessful and invasive testing completed, including documentation of a venous gradient. Venography is the gold standard of diagnostic assessment. The generally agreed upon pressure differential is 2 mmHg. The patient in this article had a differential of 8 cm. H2O pressure on either side of the right iliac artery. On exploration, the initial surgical approach should address intraluminal webs or external bands before undertaking arterial transposition.

Though there are few reported cases in the literature, iliac vein compression syndrome may be more common than reported. 5842b

EDITORIAL COMMENT
This article presents one of the youngest patients ever treated for the May-Thurner syndrome. No doubt, the patient's age entered into the decision for the particular form of venous decompression. In older patients with obstructive symptomatology, modern endovenous techniques of venous dilation and stent placement are beginning to look very good long term. The Wallstent in particular provides an excellent anatomic venous reconstruction. Logically, intimal hyperplasia in the very large common iliac vein will not prove to be a great problem.




TREATMENT OF BENIGN VENOUS STRICTURES WITH THE WALLSTENT PROSTHESIS
 Scott-Mackie PK, Irvine AT, Burnand KG
Phlebology 1996; 11:106-10

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

This article from the prestigious St. Thomas's Hospital in London describes three cases in which a Wallstent endoprosthesis was inserted for treatment of benign venous occlusive disease.

The first case describes a fit, 50-year-old man with weight-training exercises and a history of previous fracture of the left clavicle. The problem was subclavian venous thrombosis and treatment was by thrombolysis, angioplasty, and Wallstent endoprosthesis. The second patient was a 67-year-old man with carcinoma of the bladder treated by radiotherapy who presented with gradual left lower extremity venous thrombosis. Phlebography revealed a stenosis of the external iliac and common iliac veins on the affected side with treatment by angioplasty and placement of a Wallstent endoprosthesis. The third case was a 22-year-old man with history of cardiac catheterization via the right femoral artery and vein who presented with pain, night cramp, and varicose veins in the affected thigh. Treatment initially was by a panel interposition graft. As this failed at two years, retreatment was done with balloon angioplasty, and three months later by repeat angioplasty and placement of a Wallstent.

The authors point out that treatment of benign as opposed to malignant venous strictures has not been in common use. In fact, the role of stent placement in treatment of benign strictures is still unsettled but the successful outcome in these three patients indicates its possible clinical application.

COMMENTARY

An editorial in this same issue of the journal, Phlebology, points out limitations of prosthetic grafts placed in the venous system and the possible difficulties with implantation of prosthetic venous valves. This report by Professor Burnand's group provides a possible solution to the problem of prosthetic venous valves. The application of stents to treatment of venous strictures is increasing and the experience seems to be quite good.

In a report presented to the Eastern Vascular Society meeting in May 1996, the Yale group described six patients in whom subclavian venous occlusion was treated by lysis and stent placement. In two patients, first rib resection was not done. Much as in the first case of Professor Burnand,in the experience at Yale, the stents deformed because of compression between the clavicle and first rib. Others have had that same experience and, therefore, first rib resection must be considered when stent placement is decided upon in treatment of subclavian venous strictures. Nevertheless, the endovenous stent provides a nice alternative to prosthetic venous grafting and no doubt will be explored further in the future. 5921b




INITIAL EXPERIENCE WITH VENOUS STENTS IN EXERTIONAL AXILLARY-SUBCLAVIAN VEIN THROMBOSIS
 Meier GH, Pollak JS, Rosenblatt M, et al.
J Vasc Surg 1996; 24:974-83

ABSTRACT AND COMMENTARY BY:
Dhiraj M. Shah, M.D.
Albany Medical College
Albany, New York

In this paper, the authors analyze their results of thrombolysis, PTCA, and stent treatment of Paget-Schrotter syndrome in 11 consecutive patients. They recognize that because of external compression by first rib only, PTCA does not work and stent placement is necessary (done in 8 patients). When first rib resection was not done, the stent fractured in two patients. Late patency was obtained in 6 of 8 stented patients.

COMMENTARY

Paget-Schrotter syndrome (occurrence of thrombosis of the subclavian and the axillary vein) is difficult to treat. There is extrinsic compression of the vein by the first rib with intrinsic injury and thrombosis of the vein resulting in occlusion. Theoretically at best, ideal treatment strategy should focus on all components of pathophysiology, the first rib, venous wall compression, and thrombosis. Although the authors suggest that thrombolysis and stenting is an aggressive therapy, I believe immediate first rib resection should be part of the treatment strategy. Failure to do so may cause stent fracture as happened in two of their stented patients where rib resection was not done.

At our institution, we have adopted a single-stage procedure. After initial thrombolysis, the patient is treated with heparin and taken to the operating room for the first rib resection and then to the angioscopy suite for Wallstent placement. In the hospital, anticoagulation is done with heparin followed by out-patient Coumadin therapy. Of the 11 patients treated here, there has been no long-term treatment failure.

Our treatment protocol removes the pathophysiology of repeated trauma and the venous occlusion - the first by rib resection and the second by thrombolysis and stenting. This provides a long-term solution. 6244b

SUGGESTED READING

1. Chang BB, Stankin B, Clement RC III et al. One-stage definitive therapy for Paget-Schrotter syndrome: A multidisciplinary approach. Presented at the Int'l Society of Cardiovascular Surgery, Chicago, Illinois, June 1996.




INELASTIC VERSUS ELASTIC LEG COMPRESSION IN CHRONIC VENOUS INSUFFICIENCY: A COMPARISON OF LIMB SIZE AND VENOUS HEMODYNAMICS
 Spence RK, Cahall E
J Vasc Surg 1966; 24:783-87

ABSTRACT AND COMMENTARY BY:
Warner P. Bundens, M.D., M.S.
University of California, San Diego
Medical Director, CircAid Medical Devices, Inc.

In this paper, 18 lower limbs from ten patients with moderately severe chronic venous insufficiency (typical patient C6ESAS,D,PPR)1 were studied to learn the effect of no compression, graduated elastic compression (30 to 40 mmHg pressure at ankle level), and inelastic compression (CircAid ) on limb volume and venous hemodynamics.

Limb volume was monitored by measurement of ankle and calf circumference. Venous hemodynamics were evaluated with air plethysmography. Venous volume, venous filling index (measure of reflux), ejection fraction (measure of calf muscle pump efficiency), and residual volume fraction (reported to correlate with ambulatory venous pressure) were measured.2 Each patient was examined at two and six hours after arising on three separate days. Each received either no compression, the gradient stocking, or the CircAid .

Limb size was found to increase between the two- to six-hour measurements with no compression or with the gradient stocking. There was no increase with the CircAid . Venous volume decreased at two and six hours with the CircAid but not with the stockings. At six hours, ejection fraction was increased and venous filling index was decreased by CircAid but not by stockings. No significant changes were found in the residual volume fraction by either the stockings or the CircAid compared to the baseline (compression). The authors conclude that inelastic compression has significant effects on deep venous hemodynamics in this patient group and stockings do not.

COMMENTARY

Almost all patients with chronic venous insufficiency can be managed with compression therapy. Frequently, this is the best treatment that can be offered. Thus, this paper which presents objective evidence of edema prevention and hemodynamic improvement by inelastic compression is most welcome. It is also somewhat unique in directly comparing two forms of compression treatment. Hopefully, readers will be alerted to the possibility of managing chronic venous insufficiency with CircAid inelastic compression garments. In practice, they are much easier and practical to apply than other forms of inelastic compression such as non-stretch bandages and Unna boots. 6245b

REFERENCES

1. Ledig BL. Classification and grading of chronic venous disease in the lower limbs: A consensus statement. Phlebology 1995; 10:2766-69.

2. Bundens WP. Use of air plethysmography in evaluation and treatment of patients with venous stasis disease. J Dermatol Surg Oncol 1994; 21:67-69.




ENDOSCOPIC DISSECTION OF INCOMPETENT PERFORATING VEINS IN THE TREATMENT OF CHRONIC VENOUS LEG ULCERS
 Wolters U, Schmitz-Rixen T, Erasmi H, Lynch J
Vasc Surg 1996; 30:481-87

ABSTRACT AND COMMENTARY BY:
Frank T. Padberg, Jr. MD, FACS
Associate Chief of Surgery
Professor of Surgery
New Jersey Medical School
East Orange, New Jersey

The authors describe their technique for endoscopic interruption of calf perforating veins apparently completed during 1992 and 1993. Ulcers were present for 8 13 months and measured 8 3.5 cm. Limbs with "truncal or collateral varicosis" were excluded and perforating veins were demonstrated by phlebography. Doppler examinations and strain-gauge plethysmography were performed before and after the procedures. Requiring less than one hour per limb, 30 perforating veins were destroyed in 27 patients (mean age 58 years). Although two never healed, 77% of patients were ulcer free at two years. The instrumentation illustrated in the article was made by Wolf. Surgical complications were minimal and attributed to the development of this new technique.

COMMENTARY

This work emanates from Cologne, Germany. Results at two years compare favorably to previous surgical results using large, longitudinal incisions for this procedure. The endoscopic approach avoids wound complications in compromised leg skin by accessing the subfascial space from a remote site. A less obvious advantage is the reduction in length of hospital stay.

The methods describe Doppler sonography but not imaging. The venograms described were presumably standard ascending technique using a tilt table, ankle tourniquet, and dorsal foot vein injection on the non-weightbearing limb. It has been my practice to mark the incompetent perforators preoperatively in the noninvasive laboratory and to then verify their ablation following the procedure. The ablation of 1.1 veins per patient surely helped facilitate rapid completion of the surgical event.

Long-term absence of recurrent ulceration is commendable but it is difficult to attribute this result to procedure alone and not to aftercare. At any rate, patients were only asked to wear support stockings for six months. Although Table II in the article reiterates the +3 -3 scale recommended for classification of outcome following operation, this comparative data is not given.

Preoperative evaluation excluded limbs "with truncal or collateral varicosis" but the state of the deep venous system on phlebogram was not reported. The critical question of whether there was preexisting venous obstruction or deep valvular incompetence is, therefore, unanswered. It is unclear if this patient population represents the unusual entity of isolated perforator incompetence. Specifically, it would have been of interest to know whether the treated perforators derived from concomitant incompetence of the deep calf veins. Isolated perforator disease is so uncommon in most venous clinics that perforator ablation is most often performed in conjunction with other venous surgery.

In summary, the authors have demonstrated that 77% of appropriately selected limbs will remain ulcer free for at least two years following endoscopic perforator ligation. The procedure is short and effective and is not accompanied by significant complications. While they describe a two-day hospital-ization, they anticipate suitability of this procedure for ambulatory surgery. Like the authors, I am enthusiastic about the benefits of this procedure and would encourage those who have not adopted the technique to consider it. 6246b




VENOUS ULCERATION: A CROSSOVER STUDY FROM NONOPERATIVE TO OPERATIVE TREATMENT
 DePalma RG, Kowalleck DL
J Vasc Surg 1996; 24:788-92

ABSTRACT AND COMMENTARY BY:
Robert A. Cambria, M.D.
Department of Vascular Surgery
Medical College of Wisconsin
Milwaukee, Wisconsin

This paper compares the results of nonoperative management of venous ulceration in 11 patients over a three-year period with subsequent operative therapy in the same 11 patients over the next three years. Operative management consisted of a combination of extrafascial perforator division and saphenous vein stripping in the majority of patients. One also had a Palma crossover venous graft and one had superficial femoral valvuloplasty. One patient with caval occlusion was not a candidate for surgical intervention.

During the first period of nonoperative therapy, an average of 4.4 ulcer recurrences per patient were noted. Each patient experienced at least three ulcer recurrences. Following operative therapy in the second period, only two ulcer recurrences were noted among all ten patients treated. A marked time difference in the time required for ulcer healing in the two periods was also noted. Prior to operative intervention, mean time required for ulcer healing was 13 weeks and following surgical intervention, the mean time was four weeks. The clinical severity score (based on degree of edema, venous claudication, pigmentation, lipodermatosclerosis, ulcer duration, recurrence, and number) was calculated for each patient and was significantly decreased following operative intervention from 12 in the first period to 3.5 in the second period.

COMMENTARY

The results of this study are encouraging and support the aggressive evaluation and operative therapy for recurrent ulceration. In particular, this paper supports the utility of perforator division and saphenous vein stripping when these techniques are applicable. Unfortunately, the small number of patients in this study prevents drawing any far-reaching conclusions. However, it is impressive that among the ten patients, each of whom had at least three ulcer recurrences in three years, there were only two individual episodes of recurrence following surgical intervention. It is also noteworthy that both ulcer recurrences following surgical intervention occurred in patients with venous obstruction and reflux.

This paper leaves the reader without some information which may have been useful to those of us trying to select patients for operative therapy. Perforators were identified preoperatively in seven patients according to the CEAP classification. How were these detected? What was the average number and location of the perforators identified? What was the relation to the ulceration? Did the size of the ulcerations have an influence on the difference noted in time of healing between the two periods? Did these 11 patients represent the entire group with venous stasis ulceration treated over the six-year period? If not, are they representative of the entire group implying that over 90% of such patients have surgically correctable disease?

We have become more aggressive in our search for patients with venous ulceration who would benefit from surgical intervention. Certainly, in the small subset where disease is limited to the superficial veins, ablation of the saphenous vein is curative. Usually, some combination of superficial, deep, and perforator disease is present (8 of 10 patients in this study).

We have identified perforating veins using color-flow duplex in the majority of our patients but not all. Commonly, one or two perforators are located medially and we are able to identify these at surgery using endoscopic subfascial exploration. We have also identified a perforating vein associated with a chronic non-healing lateral ulceration which was divided and resulted in rapid ulcer healing. Although we treat a large population with venous ulceration, we have offered operative intervention to a small minority with ideal anatomic situations. However, we have been encouraged by our results and by reports similar to this one. As more data becomes available, these procedures will become an important adjunct to the standard therapy of compression and elevation for venous insufficiency. 6247b




LEUKOCYTE MIGRATION IN THE LEG IN RESPONSE TO EXPERIMENTAL VENOUS HYPERTENSION
 Saharay M, Addison IE, Shields DA, et al.
J Vasc Surg 1996; 26:725-31

ABSTRACT AND COMMENTARY BY:
Thomas W. Wakefield, M.D.
University of Michigan Medical Center
Ann Arbor, Michigan

This manuscript using a "skin window" technique evaluates the in vivo modulation of leukocyte function in response to venous hypertension. Twelve normal volunteers underwent placement of small dermal abrasions using a dental stone over the gaiter area of the leg and the flexor aspect of the forearm as a control. Six of the volunteers lay supine for 30 minutes, then stood supported for 30 minutes to raise the venous pressure in the leg, and then lay supine again for another 30 minutes. The membranes were changed every 15 minutes, fixed, and then stained for monocytes and neutrophils. The authors found that both in the arms and the legs, the vast majority of emigrating cells were neutrophils. However, after emigration, leukocyte locomotion within the membranes on the leg showed a significant decrease in the 30 minutes after venous hypertension while no such change was observed in the arms or when the experiment was repeated with the six volunteers lying supine for the entire period.

They concluded that after experimental venous hypertension, leukocyte migration is decreased, likely as a result of leukocyte activation with the potential for excessive local accumulation of activated leukocytes. The presence of activated leukocytes, especially in the gaiter area where the venous pressure is maximum, may lead to tissue damage and the soft tissue and skin changes consistent with chronic venous insufficiency and venous hypertension.

COMMENTARY

This paper is of interest because it may help to explain how venous hypertension can lead to the leukocyte changes that have been noted in the skin in areas where chronic venous changes occur. The most interesting finding is the decrease in leukocyte locomotion within the membranes on the leg as compared to the arm in patients who stood for 30 minutes producing venous hypertension. The authors comment that this will result in a venous pressure in the superficial veins in the leg to between 70 and 80 mmHg from their previous work.

The reason for a decrease in leukocyte locomotion may be that the leukocytes, specifically neutrophils in this case, activate, undergo respiratory burst, and release toxic substances such as free radicals. The authors speculate that the local release of cytokines from either endothelial cells or activated leukocytes may stimulate this leukocyte activation, such as interleukin-8 and macrophage colony-stimulating factors. These cytokines stimulate neutrophil migration and activation in the case of interleukin-8 and neutrophil migration inhibition while still stimulating "both neutrophil and monocyte respiratory burst priming" in the case of macrophage colony-stimulating factors. A similar process appears to occur in the vein wall itself in response to venous thrombosis, initially with emigration of neutrophils followed by monoyctes in a typical acute to chronic inflammatory pattern. Such an inflammatory response can then lead to vein wall damage and contribute to the changes in the vein wall that lead to chronic venous insufficiency.1-3

The limitations of this study include the fact that normal volunteers are used, and there certainly may be differences in the response to venous hypertension in a normal patient as compared to a patient with underlying chronic venous insufficiency and some ongoing chronic skin changes. Second, it is unclear if the "skin window" technique adequately mimicks what happens in the skin itself in a patient with chronic venous insufficiency without such an abrasion. With these limitations in mind, however, this study does suggest a connection between venous hypertension and leukocyte locomotion and suggests that further study of the inflammatory response associated with venous disease will likely produce advances in our knowledge of the basic pathophysiology of the syndrome of chronic venous insufficiency. 6277b

REFERENCES

1. Wakefield TW, Strieter RM, Wilke CA, et al. Venous thrombosis-associated with inflammation and attenuation with neutralizing antibodies to cytokines and adhesion molecules. Arterioscler Thromb Vasc Biol 1995; 15:258-68.

2. Wakefield TW, Strieter RM, Downing LJ, et al. P-selectin and TNF inhibition reduce venous thrombosis inflammation. J Surg Res 1996; 64:26-31.

3. Downing LJ, Strieter RM, Kadell AM, et al. Neutrophils are the initial cell type identified in deep venous thrombosis-induced vein wall inflammation. ASAIOJ 1996; 42:M677-M682.




PERCUTANEOUS BALLOON DILATATION WITH PRIMARY STENT PLACEMENT IN THE TREATMENT OF CENTRAL VENOUS OBSTRUCTION IN THE DIALYSIS PATIENT: ONE-YEAR FOLLOWUP
 Bhatia S, Money SR, Oschner JL, et al.
Ann Vasc Surg 1996; 10:452-55

ABSTRACT AND COMMENTARY BY:
Wayne S. Gradman, M.D.
Los Angeles, California

Three years ago the Ochsner Clinic compared operative reconstruction to percutaneous balloon dilatation (sans stent) for central venous obstruction. Most of the subjects were dialysis patients with an ipsilateral arteriovenous graft. The authors concluded that the long-term success rate of operative reconstruction exceeds that of a single percutaneous transluminal angioplasty. With repeated angioplasty, however, success rates approach those of operative reconstruction.

The present retrospective review compares essentially the same surgical group (expanded from 10 to 13 patients) to 13 patients treated from 1992 to 1995 with angioplasty and an intravenous stent. Presenting symptoms included "swelling and edema," discoloration, and pain. Six of the 13 surgical patients underwent either subclavian to internal jugular vein bypass or an internal jugular turndown procedure. Three patients underwent jugular to right atrial bypass and four underwent subclavian to innominate vein bypass. Angioplasty with stent placement was used in 9 subclavian vein obstructions and 4 innominate vein obstructions. Followup for all patients consisted of clinical examination at 6 and 12 months. Absence of edema and pain were considered the successful endpoints.

There were no operative deaths, but four patients in each group died during the one-year followup. One patient in the surgical group required a late anastomotic revision. The "patency rate" at one year is reported as 83% in the surgical group and 71% in the angioplasty/stent group. The authors conclude that surgery is appropriate for the low-risk patient with either a venous occlusion or a stent failure.

COMMENTARY

Does this new report shed fresh light on the difficult clinical decision whether to bypass the central vein obstruction surgically, stent it, or create a new access elsewhere? The authors suggest that the decision is easy. If possible, stent all venous stenoses and reserve surgery for venous occlusions and stent failures.

In my experience, the decision is not straightforward. It certainly should not be based solely on the data presented in this study. My reluctance to accept the results of this study is based primarily on its flawed design.1 Surgery or angioplasty was not offered to comparable patients. The surgical patients spanned almost two decades and in the 70s and 80s, surgery was the only treatment available for vein stenosis and occlusions. Angioplasty entered clinical practice six years ago and is increasingly used for vein stenosis. Surgery today is reserved only for selected individuals with central vein occlusion, a more advanced condition than vein stenosis.

Another weakness of the study is the disappointing short followup of only one year. The authors began collecting clinical data in 1977 from a notoriously captive group of patients, yet they suggest that "before formal treatment guidelines are developed, more long-term followup data must be accumulated." Further, there is the curious choice of symptoms used to select patients for treatment and to define clinical success. These symptoms are "swelling and edema" of the affected extremities, discoloration, and pain. In my experience, recurrent graft thrombosis, prominent

extremity veins, graft bleeding, and dialysis recirculation are equally important hallmarks of significant underlying venous hypertension. Pain is quite unusual. The authors refer to patency but seldom specify whether they are referring to the AV graft or to the central venous occlusion.

Glaringly absent is any mention of followup phlebograms, the true gold standard for analyzing interventional treatment. These factors undermine any proposed comparison between the two treatment groups.

One striking finding in this study is that 4 of 13 patients in each of the two study groups died during the followup year. I concur with the authors that surgical intervention in high-risk patients (e.g. diabetics and the elderly) is seldom warranted.

On the other hand, the conclusion that stent placement whenever possible is preferable to surgery fails to address the unfortunate truth about stents - that there is no easy surgical way to repair a central vein occlusion once a stent has failed. Subclavian vein stents often extend beyond the jugular vein into the innominate vein, precluding any surgical approach short of a thoracotomy. Stent placement is relatively contraindicated when dealing with the final or even penultimate graftable extremity. In contrast to the authors' experience, stents placed at my institution (Cedars-Sinai Medical Center) seldom last one year. Once thrombosed, they are difficult to open. Most of the extremities with central vein stents are abandoned well before the one-year mark.

My approach in individuals with a limited lifespan is to gain a few extra months from an upper extremity graft with a central vein stent. However, in younger individuals I construct a new access elsewhere without first stenting the central vein (I may later need to reconstruct these veins surgically). When the final battle for graft patency turns to the lower extremities (as it so often does) I prefer to repair iliac vein stenoses with a PTFE patch via a retroperitoneal approach. I reserve iliac vein stents for the occasional late failures of surgical repair. This algorithm has proved useful and durable.

Finally, I disagree with the authors statement that "central venous stenosis and thrombosis are complications that are being observed with increasing frequency." I have noticed a dramatic decrease in central vein problems following our deliberate policy of avoiding subclavian vein catheters for access. I urge all physicians caring for this vulnerable group of patients to do the same. 0293w

REFERENCES

1. Wisselink W, Money SR, Becker MO, et al. Comparison of operative reconstruction and percutaneous balloon dilatation for central venous obstruction. Am J Surg 1993; 166:200-205.




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


Early Restenosis Following Percutaneous Transluminal Balloon Angioplasty for the Treatment of the Superior Vena Caval Syndrome Due to Pacemaker-Induced Stenosis
Marzo KP, Schwartz R, Glanz S.
Cathet & Cardiovasc Diagn 1995; 36:128-131

This case report cites four previous vena cava stenoses which have been treated by primary balloon dilation. Early failure was reported in one of the other four and in this case, making the incidence of recurrent restenosis at least 40%. Vigorous elastic recoil at the dilation site has been noted. Therefore, it is unlikely that definitive treatment of superior vena cava stenosis and occlusion can be achieved by balloon angioplasty.


Early Diagnosis and Repair of Popliteal Artery and Vein Injuries Occurring During Arthroscopy of the Knee
Fogerty MD, Hines GL, Sutaria M.
Vasc Surg 1995; 29:501-4

It is an unfortunate fact of life that arthroscopy is sometimes followed by vascular injury. This paper emphasizes the need for venous repair at the popliteal level and correctly notes that persistent and troublesome leg edema follows simple popliteal venous ligation in this circumstance.


Need for Emergency Treatment in Subclavian Vein Effort Thrombosis
Molina JE.
J Am Coll Surg 1995; 181:414-40

Molina's large experience allows him to point out that thrombus in the location of the terminal subclavian valve leads to fibrosis and diaphragmatic stricture of the vein at that point. His presentation makes a telling point for rapid lytic therapy in situations of primary subclavian venous thrombosis.


Modern-Day Treatment of Acute Deep Venous Thrombosis
Comerota AJ.
Aust NZ J Surg 1995; 65:773-79

In this personal review, Dr. Comerota emphasizes the importance of adequacy of anticoagulant treatment and reemphasizes the importance of thrombolysis. He feels that lysis of deep venous thrombi does preserve venous valve function and points out the reasons why some patients fail to respond to thrombolytic therapy. Lastly, he details specific treatment strategies for acute deep venous thrombosis.


Placebo Treatment for Varicosity: Don't Eat It, Rub It!
Saradeth T, Resch KL, Ernst E.
Phlebology 1994; 9:63-66

In this study, 61 patients with the clinical diagnosis of varicose veins were entered into two groups, one of which received an oral placebo and the other applied a topical placebo preparation. The outcomes of foot volume, ankle circumference rheography, and subjective complaints were used, and in both groups there were significant improvements in several outcome measures. These included objective signs and subjective symptoms. Rheography study yielded significantly better results in the topical- compared to oral-treated groups. Clearly, symptoms of varicose veins are highly prone to respond to placebo. There are some indications to suggest that a topical placebo induces stronger effects than an oral one.