Phlegmasia cerulea dolens (PCD) with or without venous gangrene continues to be a
challenging clinical dilemma. The major problem with anticoagulation therapy is
that venous hypertension cannot be alleviated rapidly and the patient remains at
risk for further limb ischemia. Results of systemic infusion of lytic agents have been universally
dismal. Thrombolytic therapy, if used effectively, can provide an alternative to
traditional options. Catheter-directed delivery of urokinase has been used for the
past decade to treat upper extremity thrombus (effort vein thrombosis), superior vena
cava syndrome, and clotted arterial bypass grafts with proven success.
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. 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. 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. 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 yielded significantly better results than 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.
While few reports exist in sufficient numbers to support any particular thrombolytic
technique for PCD, at Stanford we have embarked upon use of aggressive catheter-directed
venous thrombolysis combined with systemic anticoagulation as a first-line approach. In six patients with PCD (two with venous gangrene), catheter-directed therapy
was successful in all patients and no major amputations were performed. In our opinion,
catheter-directed therapy is an excellent alternative to anticoagulation alone. Improvements continue as well in surgical approaches. Modern-day thrombectomy with temporary
creation of an arteriovenous fistula may be a suitable alternative for patients
in whom thrombolysis is contraindicated and may prevent early rethrombosis. With
continued refinement in surgical and endovascular techniques, we are optimistic that
the treatment for PCD will improve. 6676b
OBJECTIVE QUANTIFICATION OF THE CONTINUOUS-WAVE DOPPLER EXAMINATION
Harward TRS, Kraemer K, Bernstein EF, Fronek A.
Phlebology 1996; 11:62
ABSTRACT AND COMMENTARY BY:
Paul S. van Bemmelen, MD, PhD
Port Jefferson, New York
The objective of this study was to develop more objective parameters for the continuous-wave
Doppler assessment of venous obstruction. A standard cuff compression to 100 mmHg
with a cuff inflator was used in supine patients (11 with proven deep venous thrombosis by ascending venogram) and normal subjects (n = 20). A 12 cm wide cuff was
used, and compression lasted 1.5 seconds.
Five velocity curve characteristics provided diagnostic separation between normal
and obstructed venous systems. ROC curves were constructed to provide optimal cutoff
points. For a positive diagnosis of venous obstruction, the absolute velocity increase needed to be < 16 cm/sec, decay time > 1.05 sec, acceleration < 100 cm/sec2, deceleration < 30 cm/sec2, and curve duration > 0.95 sec.
COMMENTARY
This paper is a nice scholarly effort to provide objective criteria for the usually
subjective hand-held Doppler evaluation. This study confirms the findings of van
Bemmelen, et al in a 1990 study which explored the use of rapid-cuff inflation to
differentiate between normal and obstructed venous systems in conjunction with pulsed Doppler
duplex. In that series of 38 patients and 36 normal volunteers, a reduction in peak
velicity of antegrade flow was significant: 52.5 28 cm/sec versus 142.8 29.1
cm/sec. The use of curve duration is a nice additional parameter which is useful to discriminate
between normal and postthrombotic venous systems. However, given the ease and availability
of duplex imaging, I doubt that many clinicians will continue to put much trust in the hand-held Doppler examination without echoimaging (duplex) of the
veins. 6503b
THE ROLE OF VENOUS OUTFLOW OBSTRUCTION IN PATIENTS WITH CHRONIC VENOUS DYSFUNCTION
Labropoulos N, Volteas N, Leon M, et al.
Arch Surg 1997; 132:46-51
ABSTRACT AND COMMENTARY BY:
Mark H. Meissner, M.D.
Division of Vascular Surgery
Harborview Medical Center
Seattle, Washington
Both valvular incompetence and residual venous obstruction contribute to the development
of ambulatory venous hypertension which, in turn, is responsible for most manifestations
of the postthrombotic syndrome. The purpose of this study was to quantify the degree of venous outflow obstruction among 39 normal volunteers and 74 patients
with postthrombotic manifestations (skin changes in 29% of limbs and ulceration in
10%).
Subjects underwent a variable combination of air plethysmography and venous pressure
measurements with determination of the venous outflow fraction (VOF), venous outflow
resistance (VOR), and arm-foot pressure differential (A-F PD). The degree of outflow
impairment as reflected by these studies was then related to the location of obstruction
as determined by ascending phlebography or duplex ultrasonography.
Venous outflow resistance at venous pressures below 20 mmHg was not significantly
different between controls and limbs with isolated popliteal obstruction but progressively
increased in limbs with femoropopliteal, iliofemoral, and iliocaval obstruction.
Arm-foot pressure differential measurements were similar for controls and limbs with
popliteal obstruction but were significantly increased both at rest and after reactive
hyperemia in limbs with femoral, iliac, or caval obstruction. Venous outflow fraction was normal in controls and most limbs with isolated popliteal obstruction. It
tended to be lower in limbs with more cephalad (proximal) obstruction although only
approximately 50% of patients with obstruction proximal to the popliteal vein had
a reduction in VOF. Superficial venous occlusion reduced the VOF in only 9.6% of the 72 patients.
Comparison of the three hemodynamic tests suggested that the VOR provided the best
hemodynamic separation between limbs with popliteal, femoral, and iliac obstruction
and that this measurement correlated well with the A-F PD. In contrast, the VOF
agreed with the other two tests in only 56% of the limbs. The authors conclude that isolated
popliteal obstruction is usually well compensated and of limited hemodynamic significance
while hemodynamic impairment increases with progressively more proximal lesions due to a decreased potential for collateral formation. From a clinical perspective,
severe skin manifestations and ulceration were correspondingly more common with obstruction
proximal to the popliteal vein. The absence of a significant decrease in VOF with superficial venous occlusion suggests that in the presence of deep venous obstruction,
deep venous collaterals are more important than the superficial system in maintaining
venous outflow.
COMMENTARY
This paper calls attention to the fact that residual venous obstruction as well as
valvular incompetence is an important determinant of postthrombotic skin manifestations.
The severity of venous outflow obstruction is determined by the anatomic location
of the obstruction which correspondingly influences the potential for collateralization
and degree of recanalization. Progressively more proximal obstruction (femoropopliteal,
iliofemoral, iliocaval) produces hemodynamic alterations of increasing severity in comparison to isolated popliteal obstruction which is usually well compensated.
The increased prevalence of severe postthrombotic manifestations among patients
with obstruction more proximally corresponds to these more severe hemodynamic aberrations.
6430b
EDITOR'S NOTE
It is important to emphasize the fact that occlusion of superficial outflow reduces
the venous outflow fraction by less than 10%. It is becoming increasingly clear
that venous reflux is related to severe chronic venous insufficiency skin changes
and not the obstruction itself. This is a terribly important point because it implies that
removal of venous reflux improves nutrition and, according to Labropoulos's observation,
decreases the venous outflow fraction very little. John J. Bergan, MD
LATE RESULTS OF ILIOFEMORAL VENOUS THROMBECTOMY
Juhan CM, Alimi YS, Barthelemy PJ, et al.
J Vasc Surg 1997; 25:417-22
ABSTRACT AND COMMENTARY BY:
Bo Eklof, MD, PhD
Straub Clinic and Hospital
Honololu, Hawaii
Claude Juhan and his coworkers from HÙpital Nord at the University of Marseille in
southern France presented long-term results following 77 thrombectomies with temporary
arteriovenous fistula (AVF) in 75 patients with acute iliofemoral venous thrombosis.
Mean followup was 8.5 years with a minimum of five years for 50 patients and a minimum
of ten years for ten patients. This is not a prospective, randomized trial but a
well-controlled, retrospective case study.
The diagnosis was established by bilateral ascending venography. Extension into the
inferior vena cava (IVC) was noted in 34%. Thrombectomy was performed from common
femoral venotomy under general anesthesia. In IVC thrombosis, thrombectomy was performed
through a right subcostal retroperitoneal approach. AVF was constructed using saphenous
vein, end to side to superficial femoral artery. It was ligated after 6 to 8 weeks.
There was no perioperative mortality or clinically evident pulmonary embolism.
Primary iliofemoral patency was 84%.
Clinical symptoms and signs of chronic venous disease (classified according to the
reporting standards of 1988) and patency of the iliofemoral venous system (verified
by ascending venography and duplex scan) were evaluated in each case. Only limbs
with patent iliac veins were followed for competence of the femoropopliteal vein (30 limbs
at one year, 19 at five years, and 7 at ten years). Cumulative patency and competence
after five years were 84% and 80%, respectively and after 13 years, were 84% and
56%, respectively. The five-year clinical results showed 93% grade 0 to grade 1 chronic
venous insufficiency. Ten-year clinical results were 94%.
COMMENTARY
This is the largest series with a temporary AVF for acute iliofemoral venous thrombosis
with long-term followup of thrombectomy published to date. It is not a prospective,
randomized study but rather a well-controlled, retrospective case study. All patients had arteriovenograms after eight days and ascending venograms and duplex scanning
at the time of closure of the AVF at two months. All patients were followed annually
with clinical examination and noninvasive investigations. At least one new ascending venogram was obtained during late followup.
The quality of Dr. Juhan's vascular laboratory is excellent. I had the privilege
of working there during a sabbatical ten years ago. His clinical results are very
good with 94% being within grade 0 to grade 1. Iliac vein patency remained at 84%
after ten years which is important in avoiding late hemodynamic and clinical manifestations
of distal valvular incompetence due to proximal obstruction. However, there seems
to be a progressive deterioration of valvular function where 80% competence of femoropopliteal valves at five years decreased to 56% at ten years.
Juhan's results are similar to the Swedish prospective, randomized study. We found
that at five years, 37% of operated patients were free of symptoms compared to 18%
in the conservatively treated group. At ten years, these numbers were 54% versus
23%, respectively. Iliac vein patency at five years was 77% in the surgical group compared
to 30% in the conservative group. At ten years, this was 77% versus 47%, respectively.
With regard to femoropopliteal valvular competence, we found 36% of operated patients
had normal venous fuction compared to 11% of conservatively treated patients after
five years. After ten years, 32% of the surgical group had popliteal venous reflux
compared to 67% in the conservative group. In six patients with initially successful
thrombectomy without iliac vein obstruction, all were asymptomatic, all had iliac
vein patency, and three had no deep venous reflux.
Juhan's study shows that there is a place for thrombectomy in selected cases of acute
iliofemoral venous obstruction. In a time when catheter-directed thrombolysis with
stenting of the veins is en vougue
in the United States, this paper can hopefully enforce the necessity of the prospective,
randomized study which Rollins Hanlon suggested in 1968. 6680b
A MULTIDISCIPLINARY APPROACH TO THE TREATMENT OF PAGET-SCHROETTER SYNDROME
Adelman MA, Stone DG, Riles TS, et al.
JVIR 1997; 8:253-60
Sheehan SR, Hallisey MJ, Murphy TP, et al.
Ann Vasc Surg 1997; 11:149-54
ABSTRACT AND COMMENTARY BY:
James A. DeWeese, MD
Chair Emeritus, Section of Vascular Surgery
University of Rochester
Rochester, New York
The authors of these two papers have used urokinase for the initial treatment of patients
with axillosubclavian venous thrombosis presumably secondary to effort. Eleven
of the 14 patients treated by Adelman, et al. achieved complete thrombolysis within
eight days of onset of symptoms. Three patients were treated more than eight days
after onset of symptoms and only one was successfully lysed. All patients who had
complete thrombolysis remained patent at the time of followup one to four months
later (mean 20.8). They were asymptomatic, and patency was determined by duplex ultrasonography.
A transaxillary first rib resection was performed on ten patients who had successful
thrombolysis because their final venograms showed a luminal diameter reduction greater than 20% at the thoracic outlet. It is not stated whether this phlebogram
was performed with the arm at the side or in the hyperabducted position.
Sheeran, et al. reported complete lysis of the subclavian vein in 9 of the 14 veins,
residual thrombus in four, and continued occlusion in one. Six thrombotic events
were treated with urokinase plus percutaneous transluminal angioplasty (PTA). Complete
lysis was achieved in three but there was no significant change in three others.
At the time of followup of 14 patients (1 to 36 months, mean 24), eight remained
asymptomatic. Four of these had thrombolytic therapy or thrombolytic therapy plus
PTA and four had urokinase therapy followed by first rib resection. Six of the 14 patients
were still symptomatic but four of these demonstrated some improvement.
COMMENTARY
These two papers demonstrate again that thrombolytic therapy can achieve complete
or significant lysis of axillosubclavian thromboses secondary to effort in most
patients. The results are improved if therapy is begun less than a week after onset
of symptoms. There is insufficient data in these two papers to answer the question of whether
PTA or first rib resection can significantly alter the outcome following successful
thrombolytic therapy.
Although some centers are now routinely performing first rib resections on all patients
following a thrombosis, it is our hope that further studies will be done before subjecting
a patient to the first rib resection. As shown by Sheeran, et al. a post treatment phlebogram both in the neutral and hyperabducted position of the arm can demonstrate
constriction of the vein in the costoclavicular space. Hyperabduction of the arm
and sitting in the military position both result in narrowing of the costoclavicular space. Venous pressures taken in the median and antecubital vein demonstrate that
even in normal people, hyperabduction of the arm or sitting in the military position
results in elevation of venous pressure to approximately 2.5 times normal. Significant elevation of pressures more than 2.5 times normal have been seen by us only in symptomatic
patients.
Presently, therefore, we have not advocated routine first rib resection. We reserve
that operation for those patients demonstrating significant subclavian vein compression
by phlebograms or by venous pressures.
RED AND BLUE TELANGIECTASIAS: DIFFERENCES IN OXYGENATION?
Sommer A, Van Mierlo PLH, Neumann HAM, Kessels AGH
Dermatol Surg 1997; 23:55-59
ABSTRACT AND COMMENTARY BY:
Mitchel P. Goldman, M.D.
La Jolla, California
The authors evaluated 20 patients with telangiectasias either red and/or blue in coloration
on the lower limb. A high-frequency, 20 and 50 MHz ultrasound and laser Doppler
perfusion imaging were utilized to determine the oxygen concentration in these veins. Blue telangiectasias had an average oxygen concentration of 5.11 kPa whereas red
telangiectasias had an oxygen concentration of 5.9 kPa. There was a statistically
significant difference between the concentration of these two vessels. This translates
into an HbO2 concentration in red telangiectasias of 75.86% versus 68.77% in blue telangiectasias.
Thus, physicians should be aware that significant amounts of oxygen are present
in blue telangiectasias.
COMMENTARY
This information is helpful for determining the optimal treatment parameters of these
vessels with laser or intense pulsed-light therapy. We now realize that one should
target both oxygenated and deoxygenated hemoglobin. The authors speculate that their
mapping of these vessels with high-frequency ultrasound demonstrated that blood flows
via an arteriole into the arterial loop of the capillary bed and subsequently via
the venous loop of the capillary bed into a venule. They assumed that red telangiectasias are an offshoot of the arterial loop with blue telangiectasias being an offshoot
of the venous loop of the capillary.
This finding could also have clinical relevance in the prevention of punctate ulcerations.
It is well appreciated that injection of a sclerosing solution into a bright red
telangiectasia with a 3 cc syringe can produce a pressure of injection which far
exceeds that of the arterial pressure. Thus, the physician may inadvertently inject
sclerosing solution into an arteriole which would then crenate red blood cells, form
an embolus, and then give rise to punctate ulceration of the skin. Therefore, when
injecting telangiectasias, especially those that are colored red, one should inject with
very low pressures. 6682b
COMPLICATIONS OF AMBULATORY PHLEBECTOMY: REVIEW OF 1000 CONSECUTIVE CASES
Olivencia JA
Dermatol Surg 1997; 23:51-54
COMMENTARY BY:
Mitchel P. Goldman, M.D.
La Jolla, California
This review of 1000 consecutive phlebectomies performed over a four-year period in
385 patients details the author's experience with complications. The most common
complication was a blister formation in 1.3% which is often due to compression therapy.
Localized superficial phlebitis was seen in 1.1%. All other complications were extremely
rare. One can easily draw the conclusion that ambulatory phlebectomy under local
anesthesia is a safe procedure when performed properly.
The author presents two cases of skin necrosis which he believes is due to an idiosyncratic
reaction to lidocaine with epinephrine. Although he advises not using epinephrine
in the local anesthetic solution, his unfortunate experience has not been seen by
others who use epinephrine quite commonly. For example, the typical dermatologist
will perform literally thousands of minor surgeries and skin biopsies each year using
1% lidocaine with epinephrine without adverse sequelae. Therefore, it is difficult
to appreciate the necessity for eliminating this useful vasoconstrictive agent from local
anesthetic solutions. 6683b
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
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
Need for Emergency Treatment in Subclavian Vein Effort Thrombosis
Molina JE.
J Am Coll Surg 1995; 181:414-40
Placebo Treatment for Varicosity:
Don't Eat It, Rub It!
Saradeth T, Resch KL, Ernst E.
Phlebology 1994; 9:63-66