A CENTURY OF VARICOSE VEIN SURGERY (in French)
 van der Stricht JP
Ann Chir 1997; 51(7):707-709

ABSTRACT AND COMMENTARY BY:
AndrÈ Cornu-ThÈnard, MD
Jean-Francois Uhl, MD
Paris, France

In his introduction, Jean van der Stricht recalls four principles well established in Europe for more than 15 years but which deserve reiteration:

  1. All proposed surgical operations are exclusively indicated for the treatment of varicose veins and not varicose disease.

  2. As this is a benign disease, treatment must also be benign (i.e. perfectly safe).

  3. Surgical treatment has no influence on the subsequent course of the disease.

  4. Regular surveillance is essential, looking for the slightest sign suggestive of recurrence.
The first section of this paper deals with conservative hemodynamic techniques. The author has a poor opinion of these. Although they restore valve function and preserve the entire course of the saphenous vein, they achieve mediocre results. The author reviews various possibilities, including external valvuloplasty, saphenofemoral junction ligation (alone or in combination with ligation at various levels of the long saphenous vein), and the CHIVA technique. These are attractive techniques but all result in failure. He emphasizes that only truly pathological incompetent perforating veins should be operated and adds that endoscopic ligation, although theoretically very satisfying, is an operation where the means employed are disproportionate to the objective.

The second section studies hemodynamic resection. The author is convinced that this is the best technique. He emphasizes that resection must be complete to obtain a good result, the saphenofemoral junction must be ligated and sectioned, and the varicose long or short saphenous vein must be removed together with varicose collateral veins. He proposes the invaginated stripping technique.

The third section deals with techniques relating to "symptomatic" resections. Dr. van der Stricht describes Muller's technique which, under local anesthesia and through small incisions, allows resection of all varicose tissue. He describes the technique and the reasons for its success.

Dr. van der Stricht concludes that all these techniques are independent and that an operation may include stripping of the long saphenous vein, ligation of perforators, and phlebectomy. Finally, he emphasizes that postoperative followup is essential and that complementary sclerotherapy will probably be required. He recommends compression and a healthy lifestyle.

COMMENTARY

The four basic axioms indicated by the author constitute four essential truths regarding varicose vein surgery:

  1. No treatment cures this disease; surgery is only one aspect of treatment.

  2. Surgery must be simple and benign.

  3. Varicose disease is polymorphous, complex, and inexorably progressive.

  4. Followup is essential or even obligatory to minimize subsequent progression.
All of these, applicable to surgery, should also be applied to any other modality of curative treatment.

Among the various techniques described, van der Stricht prefers invaginated stripping (developed by him) and Muller's phlebectomy. Stripping of main varicose veins combined with phlebectomy of collaterals are the two basic procedures leading to the proposal of a fifth axiom: resection must be complete. We are convinced of the importance of this point. Hemodynamic surgery without resection, perfectly criticized by the author, has been shown to be ineffective for a long time. However, this CHIVA method is so theoretically attractive that in the beginning stages of its development, we all believed the discovery of a "faultless" treatment for varicose disease. While this did not prove to be the case, CHIVA did promote the absolute necessity for venous mapping prior to any treatment.

A criticism of this paper can be made concerning resection of short saphenous varicose veins. The author proposes a "good-quality phlebography before surgery." However, most surgeons have replaced phlebography with less invasive duplex ultrasound.

Dr. van der Stricht's review is purely historical with no reference to current investigations. This is explained by the fact that he personally performed phlebography preoperatively and thus understood the pathophysiological mechanisms and operated accordingly. Few surgeons have adopted this extremist approach due to the practical difficulties involved. However, in order to obtain a better assessment, surgeons should perform preoperative duplex ultrasound or at least be present during the study. This strategy, increasingly observed in France, constitutes an exact transposition of van der Stricht's very cautious and avant-garde approach.

Finally, the author compared sclerotherapy and Muller's phlebectomy, giving slight advantage to Muller's technique. In fact, these two techniques have the same major indication: non-saphenous varicose veins (residual varicose veins after stripping). Treatment with sclerosing injections is much easier to perform than phlebectomy (unless Muller's technique is performed at the same time as the stripping). The obvious advantage of the immediate results obtained with Muller's phlebectomy is likely to be supplanted by the development of ultrasound sclerotherapy.

Pre-treatment assessment must be the same whether a patient is treated by surgery or by sclerotherapy. No curative procedure can be done in 1998 without a preliminary duplex ultrasound. While clinical findings should take precedence, with varicose veins it is just the tip of the iceberg as the invisible is very often much greater than the visible. This emphasizes again the essential role of pretreatment assessment which should perhaps constitute a sixth axiom. vdcor348




HIGH LIGATION AND STRIPPING OF THE LONG SAPHENOUS VEIN USING TUMESCENT TECHNIQUE FOR LOCAL ANESTHESIA
 Proebstle TM, Paepcke U, Weisel G, Gass S, Weber L.
Dermatol Surg 1998; 24:149-53

ABSTRACT AND COMMENTARY BY:
Peter Conrad, FRCS, FRCS(Ed), FRACS, FACS(USA)
Sydney, Australia

There is no doubt that a worldwide interest exists in performing surgery for varicose veins under some form of local anesthetic technique. Various approaches include femoral block with local anesthetic infiltration or pure local anesthetic without nerve block. Local anesthetic may be added to neuroleptic sedation. These forms of local anesthetic are well adapted to ambulatory phlebectomy and decrease the cost of that procedure since the phlebectomy can be performed outside of the more expensive hospital setting. For hospitalized patients, local anesthetic can be used for those at risk for general anesthetic and it is well suited to those patients who prefer to avoid a general anesthetic. One disadvantage of local anesthetic techniques is that in general it is more time consuming.

The tumescent local anesthetic technique is an exciting new development for ambulatory phlebectomy. This paper is timely and answers a number of questions which relate to tumescent local anesthesia although not all of the questions which arise are actually answered. The paper does confirm that tumescent local anesthesia is a viable form of local anesthesia for ambulatory phlebectomy. In some cases, it does not appear to obviate the need for associated sedation or neuroleptic anesthesia. The tumescent technique allows huge volumes of very dilute local anesthetic solution to be used safely. In the present report, up to one liter of infusion was used. However, Gerhard Sattler of Darmstadt has reported to me a personal series of 2500 liposuction procedures in which he has used up to six liters of local anesthetic solution without significant complications. It is obvious that sufficient local anesthetic solution can be injected safely, and bilateral varicose vein operations can be done without anesthetic complication.

COMMENTARY

Although this paper reports that patients were kept in the hospital for 24 hours for observation, it is apparent that those without general risk factors can be discharged home shortly after surgery, making tumescent anesthesia ideal for office operations. In fact, the 24-hour observation reported by this paper negates the advantages of ambulatory phlebectomy. Our own experience with doing ambulatory phlebectomy under local anesthesia is that patients can walk immediately and are pain free for a long time postoperatively. These advantages seem to be even more true using tumescent local anesthesia.

The unanswered questions are as follows: In our experience, patients treated by invagination stripping of the greater saphenous vein combined with stab avulsion of varicose clusters using 3 mm incisions under

light general anesthesia are safely discharged home within a few hours of placing the dressings. It may be necessary to do a well-controlled trial to decide if tumescent local anesthesia is better than local anesthesia or light general anesthesia. This paper reports five patients who had moderate postoperative bleeding through the bandages up to four hours' postoperatively. This is a worry as we have not seen this complication in a large number of patients having similar surgery under general anesthesia.

In conclusion, it is felt that ambulatory phlebectomy using tumescent local anesthesia is an interesting new technique. In our view, it will have a place in the surgical treatment of varicose veins where the procedure is done in an outpatient setting or where the patient is unable or unwilling to tolerate general anesthesia. ivdfcon


EDITOR'S COMMENTARY

 We have been attracted to the use of tumescent local anesthesia with intravenous sedation in performing saphenous vein stripping from groin to knee as well as stab avulsion of clusters of varicose veins. We observe that there is much less ecchymosis produced by the tumescent local anesthesia technique and this may be due to the added adrenalin solution. Furthermore, the excessive drainage noted in five patients in the present paper may be due to the large volumes of anesthetic used and the normal drainage through infusion ports. A bulky dressing following phlebectomy using tumescent anesthesia is a good addition to the technique.
John J. Bergan, M.D.




OF WHAT HEMODYNAMIC SIGNIFICANCE IS REFLUX IN THE FEMORAL AND POPLITEAL VEINS
 Recek C, Hammerschlag A.
Phlebologie 1998; 27:15-28

ABSTRACT AND COMMENTARY BY:
Prof. Dr. Mehmet Kurtoglu
First Aid and Emergencies Department
University of Istanbul
Istanbul, Turkey

The authors present an interesting finding regarding the reversibility of deep venous valvular reflux. They present 14 patients with mild venous insufficiency of grades 0 to 1 according to the Widmer classification. All of these patients had lesser saphenous venous insufficiency. Their principal observation is that the deep venous valvular insufficiency disappeared after ligation of the lesser saphenous vein.

However, the objective methodology used to determine presence and, postoperatively, the absence of deep venous reflux was strain-gauge plethysmography and duplex ultrasonography. The study raises some serious questions. If there is no valve present in the popliteal vein, then popliteal reflux is a normal physiologic response to lesser saphenous valvular insufficiency. Popliteal valvular insufficiency is diagnosed by duplex when the popliteal valve is seen to reflux. This requires that the valvular insufficiency is diagnosed preoperatively and then the valves shown to be competent postoperatively. This was done by duplex ultrasound imaging. Duration of popliteal reflux is also important. In the standing position, duplex ultrasound-diagnosed reverse flow must exceed 0.5 seconds and in the trunk-elevated investigations should exceed one or two seconds. Reflux duration shorter than this is probably a normal physiologic response.

There is ample documentation that plethysmographic instruments do not discriminate well between deep and superficial reflux nor do their measurements correlate with various degrees of chronic venous insufficiency. I believe plethysmography has a limited clinical use as the only objective parameter employed in assessing venous valvular incompetence. Therefore, this study is of considerable importance. ivdfkur

SUGGESTED READING

1. van Bemmelen PS, Mattos MA, Hodgson KJ, et al. Does air plethysmography correlate with duplex scanning in patients with venous insufficiency? J Vasc Surg 1993; 18:796-807.

2. Christopoulos D, Nicolaides AN, Szendro G. Venous reflux: Quantification and correlation with the clinical severity of chronic venous disease. Br J Surg 1998; 75:352.

3. Weingarten MS, Branas CC, Czeredarczuk BA, Schmidt JD, Wolferth Jr CC. Distribution and quantification of venous reflux in lower extremity chronic venous stasis disease with duplex scanning. J Vasc Surg 1993; 18:753-59.


EDITOR'S NOTE

 This article was chosen because of the importance of the subject. That is, the evaluation of patients before and after therapy by objective techniques will yield extremely valuable information in the planning of subsequent therapy in other patients. The phenomenon of deep venous reflux caused by superficial venous reflux has been referred to as secondary reflux and is an important observation. The fact that it can be evaluated by duplex scanning has already yielded valuable information about the reversal of such reflux.

The second reason for choosing this article for commentary was the opportunity to provide readers of the Venous Digest a reference list on validation of various forms of noninvasive testing and how they compare with one another. I am providing the list below and it is hoped that accurate, up-to-date, objective investigations will be chosen for evaluation of patients pre- and postoperatively.
John J. Bergan, M.D.

REFERENCES

1. van Bemmelen PS, van Ramshorst B, Eikelboom B. Photoplethysmography reexamined: Lack of correlation with duplex scanning. Surgery 1992; 112:544-48.

2. Welch HJ, Faliakon EC, McLaughlin RL, Umphrey SE, Belkin M, O'Donnell Jr TF. Comparison of descending phlebography with quantitative photoplethysmography and duplex quantitative valve closure time in assessing deep venous reflux. J Vasc Surg 1992; 16:913-19.

3. Bays RA, Healy DA, Atnip RG, Neumyer M, Thiele BG. Validation of air plethysmography, photoplethysmography, and duplex ultrasound in the evaluation of severe venous stasis. J Vasc Surg 1994; 20:721-27.

4. Neglen P, Raju S. A rational approach to detection of significant reflux with duplex Doppler scanning and air plethysmography. J Vasc Surg 1993; 17:590-95.

5. Raju S, Fredricks R. Evaluation of methods for detecting venous reflux. Arch Surg 1990; 125:1463-67.

6. McMullin GM, Coleridge Smith PD, Scurr JH. A study of tourniquets in the investigation of venous insufficiency. Phlebology 1991; 6:133-39.




SUBCLAVIAN VEIN THROMBOSIS: OUTCOME ANALYSIS BASED ON ETIOLOGY AND MODALITY OF TREATMENT
Beygui RE, Olcott IV C, Dalman RL
Ann Vasc Surg 1997; 11:247-55

ABSTRACT AND COMMENTARY BY:
Ali F. AbuRahma, MD
Professor of Surgery
Chief, Vascular Section
Medical Director, Vascular Laboratory
Charleston Area Medical Center
Charleston, West Virginia

This study reviews the experience with subclavian vein thrombosis (SVT) of one institution over a seven-year period. It compares the results of treatment based on cause of thrombosis. Nineteen patients suffered SVT secondary to malignancy, catheter placement, radiation, or hypercoagulability. Thirteen others had primary effort vein thrombosis. Thrombolysis, defined by complete obliteration of the clot, was achieved in 31 of 32 patients. Adjunctive treatment to relief external compression or to improve luminal contour was performed on 16 of the 32 patients (eight effort thrombosis and eight secondary SVT). Only eight were ultimately successful.

Adjunctive treatment included balloon angioplasty in six, stent placement in five, first rib resection and scalenectomy in four, and vein reconstruction in four. Initial treatment success with lytic therapy was achieved in 26 of 31 patients (84%). Angioplasty failed in three patients with effort vein thrombosis and in three with secondary vein thrombosis. Stent placement was successful in two of five patients with secondary SVT.

Surgery was performed on eight patients with effort vein thrombosis. First rib resection and scalenectomy was successful in four of four patients, and vein reconstruction was successful in two of four patients.

A significant incidence of adjunctive treatment failure was noted in every category except first rib resection and scalenectomy. Balloon angioplasty of the subclavian vein following lytic therapy to correct residual venous abnormalities was remarkably unsuccessful in every patient category in which it was attempted. The authors feel that the addition of intraluminal stenting has improved the outcome following angioplasty in selected patient categories although they have avoided subclavian vein stent placement in patients with axillary subclavian vein thrombosis due to the possibility of stent failure from external compression.

The authors conclude that the results of SVT therapy, including lysis and oral anticoagulation, were very good. Twenty-eight patients were given long-term oral anticoagulation with good long-term results. Angioplasty and stent placement in patients with secondary SVT appeared to add little long-term benefit. They also concluded that surgery may improve the outcome in selected patients with primary effort vein thrombosis although the additional benefit could not be determined by the design of this study. The authors caution that the design of this study precludes drawing definitive conclusions regarding the success of anticoagulant therapy due to limited long-term followup.

COMMENTARY

Several previous investigators have used oral anticoagulation as the sole therapy for patients with subclavian vein thrombosis with a reported clinical success rate of 30 to 100%. However, lytic therapy, as was accomplished in 31 of 32 patients in this series, may ultimately improve the efficacy of oral anticoagulation and may partially explain the improved results of oral anticoagulation as compared to historical series. The effect of lytic therapy prior to oral anticoagulation has previously been suggested by others and by us.1,2

A study of 19 patients with axillary subclavian vein thrombosis compared the early and late results of lytic versus anticoagulant therapy for both spontaneous and secondary axillary subclavian vein thrombosis. Nine patients underwent conventional treatment (heparin and warfarin, group 1) and ten had initial lytic therapy followed by heparin and warfarin (group 2). Three patients had cervical or first rib resection. Thirteen patients had spontaneous thrombosis and six of these were secondary to central venous catheterization.

At a mean followup of 36 months, two of nine patients (22%) in group 1 and eight of ten (80%) in group 2 had total venous recanalization and symptom resolution (p = 0.018). In the spontaneous axillary subclavian vein thrombosis subset, one of six patients (17%) in group 1 and five of seven (71%) in group 2 had total venous recanalization and symptom resolution (p = 0.078). The average difference in cost between group 1 and group 2 was $19,000. At that time, it appeared that lytic therapy was superior to anticoagulation therapy in the treatment of axillary subclavian vein thrombosis; however, such treatment was more expensive. The benefit should be weighed carefully against the cost in each case.

More objective data regarding subclavian vein lumen patency following lytic therapy and anticoagulation is needed, including comprehensive followup with duplex scanning of he subclavian vein in all patients before any recommendation regarding surgery versus lytic the can be made. The lack of objective followup data for the patients in this series poses questions regarding the significance of their clinical success. Similarly, the length of time (mean of seven months) encompassed by this series limits the significance of this data.

It is generally felt that clinical outcome following SVT treatment including, at a minimum, catheter-directed lytic and oral anticoagulation therapy is very good. Balloon angioplasty appears to be ineffective regardless of etiology. Stent placement may improve the results of angioplasty in selected patients without effort vein thrombosis and surgery may improve outcome in effort vein thrombosis patients with external compression or intrinsic venous abnormalities. vdabu349

REFERENCES

1. Machleder HI. Evaluation of a new treatment strategy for Paget-Schroetter syndrome: Spontaneous thrombosis of the axillary subclavian vein. J Vasc Surg 1993; 17:305-17.

2. AbuRahma AF, Short YS, White III JF, Boland JP, Treatment alternatives for axillary subclavian vein thrombosis: Long-term followup. Cardiovasc Surg 1996; 4(6):783-87.




OCCULT DEEP VENOUS THROMBOSIS COMPLICATING SUPERFICIAL THROMBOPHLEBITIS
Blumenberg RM, Barton E, Gelfand ML, Skudder P, Brennan J.
J Vasc Surg 1998; 27:338-43

ABSTRACT AND COMMENTARY BY:
Enrico Ascher, MD
Anil Hingorani, MD
Division of Vascular Surgery
Maimonides Medical Center
Brooklyn, New York

The authors of this article have reviewed their experience with superficial venous thrombosis (SVT) associated with deep venous thrombophlebitis (DVT) over a two-year period. Diagnosis was made by standard duplex scan protocol. Of the 8318 lower extremity lower extremity duplex scans performed, they found 232 documented cases of SVT, 14 of which were noted to extend into the deep venous system. Of the cases involving the deep venous system, 10% suffered pulmonary embolism. The authors conclude that SVT is not always benign or self limiting and that routine imaging be used to rule out involvement of the deep system in cases of SVT.

The authors attempted to shed some light on a poorly understood field. While many clinicians routinely diagnose SVT based on clinical examination and treat with warm compresses and aspirin, these data suggest that some of those patients may have occult concomitant deep venous thrombosis or extension into the deep venous system and, therefore, are not receiving appropriate treatment. The concept that SVT may be accompanied by DVT or that it may extend into the deep venous system in 11 to 30% of cases is not new.1-4 Nevertheless, this retrospective review does add to the growing body of literature supporting this concept and raises several important questions.

Of the 51 patients who had followup duplex scans, six had extension of the SVT to DVT. While these 51 patients may have undergone the second scan because of more symptoms, this raises the question of which patients should undergo followup scans and at what interval. The authors empirically suggest that SVT patients should undergo repeat duplex at two days and six days after the first scan. Are there some prognostic factors that may aid in predicting the patient at high risk for progression of SVT? Unfortunately, little published data is available to answer these questions.

COMMENTARY

Since this review was based on the duplex database of the authors' institution and no data is given on the type of treatment given, the effect of treatment on the observed incidence of DVT or extension cannot be commented upon. In fact, the optimal treatment for patients with proximal SVT is still under debate. While some suggest that these patients be observed, some suggest high ligation of the greater saphenous vein.5,6 We have suggested that patients with SVT in proximity to the saphenofemoral junction or patients with ascending thrombosis undergo systemic anticoagulation for an arbitrary period of six weeks. Over the last ten years, we have treated over 60 patients with SVT in such a manner with routine duplex followup and have not encountered significant morbidity.7 However, a comparison between operative and nonoperative therapy for proximal SVT is lacking in the literature.

While the issue of non-contiguous DVT is not addressed in this review, the high incidence of concomitant DVT not in continuity with SVT found in other studies suggests that this would have been encountered had been looked for. This would further lend support to the concept that patients with suspected SVT should undergo a complete survey of the lower extremity venous system.2,4,7

While this paper adds weight to the concept that SVT should not be viewed as an unimportant disease process, it does not add significant new information that has not been previously explored. Instead, it underscores how little is known about this entity. vdash

REFERENCES

1. Chengelis DL, Bendick PJ, Glover JL, Brown OW, Ranval TJ. Progression of superficial venous thrombosis to deep venous thrombosis. J Vasc Surg 1996; 24:745-49.

2. Skillman JJ, Kent KC, Porter DH, Kim D. Simultaneous occurrence of superficial and deep thrombophlebitis in the lower extremity. J Vasc Surg 1990; 11:818-23.

3. Guex JJ. Thrombotic complications of varicose veins. A literature review of the role of superficial venous thrombosis. Dermatol Surg 1996; 22:378-82.

4. Jorgensen JO, Hanel KC, Morgan AM, Hunt JM. The incidence of deep venous thrombosis in patients with superficial thrombophlebitis of the lower limbs. J Vasc Surg 1993; 18:70-73.

5. Plate G, Eklof B, Jensen R, Ohlin P. Deep venous thrombosis, pulmonary embolism, and acute surgery in thrombophlebitis of the long saphenous vein. Acta Chir Scand 1985; 151:241-4.

6. Lohr JM, McDevitt DT, Lutter KS, Roedersheimer LR, Sampson MG. Operative management of greater saphenous thrombophlebitis involving the saphenofemoral junction. Am J Surg 1992; 164:269-75.

7. Ascher E, Lorensen E, Pollina RM, Gennaro M. Preliminary results of a nonoperative approach to saphenofemoral junction thrombophlebitis. J Vasc Surg 1995; 22:616-21.




RISK OF DIAGNOSIS OF CANCER AFTER PRIMARY DEEP VENOUS THROMBOSIS OR PULMONARY EMBOLISM
 Sorensen HT, Mellemkjaer L, Steffensen FH, et al.
New Engl J Med 1998; 338:1169-73

PRIMARY VENOUS THROMBOEMBOLISM AND CANCER SCREENING: AN EDITORIAL
 New Engl J Med 1998; 338:1221

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

For over a century, there has been a suspected association between cancer and venous thromboembolism caused by hypocoagulability due to the activation of clotting factor by tumor cells, vessel wall injury and/or stasis. Thrombotic events have been reported to occur before the diagnosis of cancer and it was suggested that deep venous thrombosis may predict the subsequent diagnosis of cancer.

Prandoni, et al. (N Engl J Med 1992; 327:1128) followed 145 patients over a two-year period and found 11 cases of cancer compared with two cases in 105 patients with secondary venous thrombosis (odds ratio 2.3). The incidence of cancer in patients with recurrent idiopathic venous thrombosis was higher than in patients without this condition (odds ratio 4.3). Likewise, Nordstr–m, et al. (Br Med J 1994; 308:891) evaluated 1183 patients in a hospital-based study with deep venous thrombosis and found five times the risk of cancer in those patients as compared to the general population during a six-month followup.

The present evaluation involves a nationwide study of patients with deep venous thrombosis or pulmonary embolism derived from the Danish National Registry of Patients from 1977 through 1997. Linkage was determined through the Danish National Cancer Registry and the expected number of cancer cases was estimated on the basis of national age, sex, and sites of specific incidence. A total of 15,384 patients with deep venous thrombosis and 11,305 with pulmonary embolism were identified with 1737 cases of cancer noted in the deep venous thrombosis group compared with 1372 expected cases (standardized incidence ratio 1.3 (95% confidence interval 1.2 to 1.33). In the pulmonary embolism group, the standardized incidence ratio was also 1.3 (95% confidence interval 1.22 to 1.41. The risk was elevated only during the first six months of followup and declined thereafter to a constant level above 1.0 one year after the thrombotic event. It was noted that 40% of patients given a diagnosis of cancer within one year after hospitalization for deep venous thrombosis had distant metastasis at the time of diagnosis of the cancer. This proved that there was a strong association with several cancers (pancreas, ovary, liver, brain). The authors suggest that an aggressive search for hidden cancer in a patient with primary deep venous thrombosis or pulmonary embolism is unwarranted.

COMMENTARY

The positive and negative aspects of this paper have been elegantly evaluated by B¸ller and Cate in their editorial. The difference in standardized incidence ratio from study to study may well be the result of the changing ability to diagnose deep venous thrombosis. The Danish study spanned from 1977 to 1992, a time when the diagnosis of deep venous thrombosis moved from physical diagnosis to advanced imaging. It has been estimated that approximately 50 to 70% of symptomatic patients are misdiagnosed at the bedside.

Despite these statistical inconsistencies, it is apparent that 40% of patients with a cancer diagnosis within one year after hospitalization for thromboembolism had distant metastasis. This would suggest a strong association between at least early-stage cancer and thromboembolism.

While the authors do not recommend an aggressive cancer evaluation in patients with deep venous thrombosis, aggressive has different meaning to different clinicians. Obviously, all these patients would have undergone a comprehensive history and physical examination, routine laboratory testing, and chest xray. In the gynecological patient, a pelvic examination and possibly a transvaginal sonography would be part of the physical examination. As ovarian cancer is found to be associated with emboli, CA-125 antigen determination is thought accurate in 60 to 70% of cases. Further, a CA-125 antigen can be elevated in cases of carcinosarcoma, a particularly aggressive uterine cancer. It should be remembered that CA-125 antigen of often found positive in patients with moderate to severe endometriosis and therefore its interpretation should be handled carefully. Likewise, measurement of prostate specific antigen is certainly noninvasive but its utility is controversial.

As B¸ller and Cate note, it is a moot point if one detects cancer in its most advanced stage. They correctly point out that 40 to 60% of cancers which appear after venous thromboembolism are not metastatic at the time of detection. Therefore, one might argue that the younger the patient the more aggressive the search should be, guided by the natural history of the associated cancers that appear in those age groups. vdbla350