RADIOLOGIC VERSUS SURGICAL PLACEMENT OF VENA CAVA FILTERS: A COMPARATIVE STUDY OF COST, TIME AND COMPLICATIONS
 Bhatia RS, Collingwood P, Bartlett P.
Can Assoc Radiol J 1998; 49:79-83

ABSTRACT AND COMMENTARY BY:
Paul H. S. Bloch, MD
Jock R. Wheeler, MD
Eastern Virginia Medical Center
Norfolk, Virginia

Inferior vena cava filters (IVCF) effectively prevent pulmonary embolism.1 This study of 30 patients compares cost, time, and complications of IVCF placement between the radiology service and the surgical service in a Canadian hospital. This retrospective study compares two nonconcomitant groups of patients. The first 15 studied had previously undergone Greenfield IVCF placement on the surgical service via venous cutdown. The next 15 patients underwent radiologic (percutaneous) placement of the Vena Tech LGM IVCF in the angiography suite.

In this study, Greenfield IVCF procedures via venous cutdown required general anesthesia, took an average of 30 minutes longer than the percutaneously placed filters, and were performed without an inferior vena cava imaging study. Vena Tech filters placed in the angiography suite had shorter booking times, shorter waiting times, and cost an average of $702 (Canadian dollars) less than the Greenfield filter placements. Three ancillary professional personnel were required in both groups and an anesthesiologist was required in the cutdown group. The more expensive Greenfield filter accounted for 80% of the total cost difference with 26% of the cost difference accounting for anesthetic supplies and anesthesiologist fees.

Early and delayed complication rates were similar between the two groups. These included poor opening (2 in the percutaneous group), filter tilt > 15 degrees (2 in the cutdown group), bleeding (1 in each group), incorrect positioning or IVCF migration (1 in the cutdown group), and inability to complete the placement (1 in each group). There were no long-term complications (pulmonary embolism, IVC perforation, filter fracture) after a mean seven-month followup.

COMMENTARY

The rationale for this study is inherently flawed. Percutaneous IVCF placement has been available for several years.2,3 Few would dispute the advantages of percutaneous over cutdown techniques. These advantages exceed considerations of cost and time requirements. Ease of placement, patient acceptance, and patient comfort are also significant issues. Cutdown for routine IVCF placement is, or should be, obsolete. Furthermore, the authors' labeling of percutaneous endovascular techniques as "radiologic" is unacceptable. Percutaneous and endovascular techniques have been developed, investigated, and reported by both surgeons and radiologists.4-9 Poor study design allows for the possibility that those placing IVCF in the percutaneous group could have purposefully taken measures to decrease turnover times in anticipation of the study. Finally, low patient numbers in each study group prohibit meaningful conclusions.

Imaging of the vena cava is required for IVCF placement. Although Greenfield IVCFs have been placed in vena cavas up to 28 mm10, enlarged vena cavas are not uncommon. In addition, vena cava anomalies including double vena cava are encountered in up to 2.1% of cases.11 In this study, failure to perform an imaging study in the cutdown group was an error and may have accounted for the single incident of filter migration. A large number of patients in the percutaneous group (13%) had poor opening of the Vena Tech IVCF. This is likely a result of technical error resulting from very rapid deployment of the Vena Tech IVCF. In our experience, we observe that the Vena Tech IVCF is successfully deployed by using a maneuver in which the initial unsheathing of the filter is performed slowly (the filter struts are noted to "flower" at the tip of the deployment device), after which time the device is rapidly and completely unsheathed.

This study is more a comparison of IVCF devices than of IVCF placement techniques. The complications described are highly indicative of the types of filter employed. Tilting of the Vena Tech filter rarely occurs because of its structural design (the stabilizer bar at the end of each strut). Moreover, IVCF tilt, although a measurable outcome, may be of little or no significance.12 Additionally, the study to which the author refers3 has a 4.4% tilt rate, not 11% as the author stated (page 83).

Finally, this study demonstrates that the technically unsophisticated percutaneous technique was compensated at greater levels (average of 32% greater procedural fee in the percutaneous group, not including interpretation fees) than the more technically demanding open technique. This is solely because the percutaneous technique employs current technology. Further discussion on this matter is beyond the scope of this commentary. At our center, we have investigated duplex-directed IVCF placement (DDCF).13 Using ultrasound technology, we image the inferior vena cava and renal veins. With duplex guidance, we perform percutaneous bedside (Vena Tech LGM) IVCF placement in critically ill and multi-trauma patients under local anesthesia requiring only three personnel (ultrasound technologist, ICU nurse, and surgeon). We employ this procedure successfully in 98% of patients. Most DDCF are placed in 30 minutes or less (96%) and can usually be done in 15 minutes or less if the inferior vena cava is well visualized. Cost savings are tremendous (DDCF $2850, radiology $4100, operating room $5100). Patients who fail the DDCF method have an IVCF placed under fluoroscopic guidance in either the angiography suite or the operating room. vdwhe136

REFERENCES

1. Greenfield LJ, Proctor MC. A 20-year experience with the Greenfield filter. Cardiovasc Surg 1995; 3:199-205.

2. Greenfield LJ, Proctor MC, Roberts KR. An improved process for development and testing of vena cava filters: The percutaneous steel Greenfield filter. Surgery 1997; 121:50-57.

3. Ricco JB, Dubreuil F, Reynaud P, et al. The LCM Vena Tech Caval Filter: Results of a multicenter study. Ann Vasc Surg 1995; 9(Suppl):S89-100.

4. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography. A new technique. Acta Radiol 1953; 39:368.

5. Dotter CT, Judkins MP. Transluminal placement of arteriosclerotic arteriography: Description of a technique and a preliminary report of its application. Circulation 1964; 30:654-70.

6. Casteneda-Zuniga WR, Formanek A, Tadavarthy M, et al. The mechanism of balloon angioplasty. Radiology 1980; 135:565-71.

7. Kirkemo A, Johnston MR. Percutaneous placement of the Hickman catheter. Surgery 1982; 91:349-51.

8. Fogarty TJ, Kinney TB. Intraoperative coronary artery balloon catheter dilatation. Am Heart J 1984; 107:845-51.

9. Cull DL, Wheeler JR, Gregory RT, et al. The Vena Tech filter: Evaluation of a new inferior vena cava interruption device. J Cardiovasc Surg 1991; 32:691-96.

10. Greenfield LJ. Cost versus value in vena cava filters. Chest 1998; 114:9-10.

11. Bartle EJ, Pearce WH, Sun JH, Rutherford RB. Infrarenal venous anomalies and aortic surgery: Avoiding vascular injury. J Vasc Surg 1987; 6:590-93.

12. Greenfield LJ, Proctor MC, Cho KJ, Wakefield TW. Limb asymmetry in titanium Greenfield filters: Clinically significant? J Vasc Surg 1997; 26:770-75.

13. Sato DT, Robinson KD, Gregory RT, Gayle RG, et al. Duplex-directed caval filter (DDCF) insertion in multi-trauma and critically ill patients. Submitted for publication.




FIVE-YEAR FOLLOWUP OF PROPHYLACTIC VENA CAVA FILTERS IN HIGH-RISK TRAUMA
 Rogers FB, Strindberg G, Shackford SR, et al.
Arch Surg 1998; 133:406-11

COMMENTARY BY:
Panos B. Dimakakos, MD, FICS, FICA, PACA
Professor of Vascular Surgery
Medical School, University of Athens
Athens, Greece

This study deals with the short and long-term results of vena cava filter placement in high-risk trauma patients. In a total of 132 patients with contraindication to anticoagulant medication and/or spinal cord injury with neural deficits, severe head injury, or pelvic and long bone fractures, 86.3% had placement of a Greenfield, 7.6% had placement of a Vena Tech filter, and 6.1% had placement of a bird's nest filter. All vena cava filters were placed percutaneously. Followup was done with ultrasonography. Mean followup time was 599 days (9 to 1946 days).

Thrombosis related to vena cava filter placement was observed in four cases (3%) while thrombosis was seen in six (4.5%) during hospitalization following vena cava filter placement. Pulmonary embolism following insertion of the filter was observed in three cases (2.8%), one of which was fatal. An asymptomatic inferior vena cava thrombosis was detected in one patient after discharge from the hospital. Patency of the vena cava was 97.1% ( 29) at bypass by life-table analysis.

COMMENTARY

In 1986, the National Institutes of Health Consensus, acknowledging the increased danger of thromboembolic disease in trauma patients, suggested a prospective, randomized study for this population.1 The studies that followed confirmed a 20 to 65% thrombosis with a higher incidence of pulmonary embolism in selected high-risk trauma patients.2 Seven years later, the American College of Surgeons' Committee on Trauma recognized deep venous thrombosis and pulmonary embolism as preventable complications in trauma.3

It is a fact that one in seven trauma patients cannot receive anticoagulant therapy because of associated injuries. It is also true that up to one-third of trauma patients cannot effectively use a pneumatic compression device4 and that the administration of anticoagulant medication is not allowed in 14% of high-risk trauma patients.5 It is in these patients that the placement of vena cava filters has proved effective in the prophylactic management of pulmonary embolism. The concomitant use of ultrasonography in the placement of vena cava filters and in the detection of thrombosis at followup is important. Pulmonary embolism and fatal pulmonary embolism has become a rarity,6 and filter patency has remained at 96 to 98%.2 The risks of filter placement (thrombosis, hemorrhage, penetration, filter migration) are very limited and the incidence of each is fairly rare.

Several studies suggest that prophylactic anticoagulant therapy protects patients with major trauma from deep venous thrombosis and pulmonary embolism. For those with long life expectancy who cannot receive prophylactic anticoagulation therapy, the use of a temporary or retrievable filter is suggested. That idea requires further study.

This prospective study, one of the largest with the longest followup, has shown that the timely placement of vena cava filters in selected trauma patients constitutes a safe and effective method of controlling pulmonary embolism without actually affecting the return of the venous flow from the lower extremities and the inferior vena cava. ivdfdim

REFERENCES

1. Consensus Conference. National Institutes of Health. Prevention of venous thrombosis and pulmonary embolism. JAMA 1988; 256:744-49.

2. Headrick JR, Barker DE, Patella CM et al. The role of ultrasonography and inferior vena cava filter placement in high-risk trauma patients. Am Surgeon 1997; 63:1-8.

3. Committee on Trauma. American College of Surgeons. Resources for the Optimal Care of the Injured Patient. Chicago, American College of Surgeons, 1993.

4. Shackford SR, Davis JW, Hollingsworth-Frid-Lund P, et al. Venous thromboembolism in patients with major trauma. Am J Surg 1990; 159:365-69.

5. Nunn CR, Neuzil D, Naslund T, et al. Cost-effective method for bedside insertion of vena cava filters in trauma patients. J Trauma 1997; 43:752-58.

6. Khansarinia S, Dennis JW, Veldenz HC et al. Prophylactic Greenfield filter placement in selected high-risk trauma patients. J Vasc Surg 1995; 22:231-36.




RESULTS OF TREATMENT OF INFERIOR VENA CAVA SYNDROME WITH EXPANDABLE METALLIC STENTS
 Fletcher WS, Lakin PC, Pommier RF, Wilmarth T.
Arch Surg 1998; 133:935-38

ABSTRACT AND COMMENTARY BY:
Paul R. Cordts, LTC MC
James F. Tretter, MAJ MC
Denise M. Uratake, RVT
Teddie S. Gawley, RN, RVT
Department of Surgery, Vascular Surgery Service
Tripler Army Medical Center, Hawaii

This is a retrospective review of 28 patients with inferior vena cava (IVC) syndrome due to hepatic metastases (27) or primary tumor (1) who underwent percutaneous transfemoral placement of a retrohepatic IVC stent. Of the 28 stents, 27 were Gianturco-Rosch self-expandable Z-metallic stents (Cook, Bloomington, Illinois, USA) and one was a Wallstent (Schneider, Inc., Plymouth, Minnesota, USA).

Reduction in pressure gradients before and after stent placement varied from 18 to 100% (mean 73.9%). Before and after weights were obtained in 12 patients. Weight loss varied from 1.35 to 10.35 kg (mean 5.85 kg). Twenty-six of the 28 patients (93%) had documented lower extremity edema and 19 (68%) had documented ascites prior to stent placement. The authors state that patients experienced "dramatic" reduction in these symptoms post stent placement until patient death due to lack of a clinical picture consistent with IVC occlusion (no followup venography or duplex scans were performed). Mean patient survival was 34 days.

Two complications occurred. One IVC thrombus necessitated placement of an additional stent on the first day following the initial stent. One pulmonary embolism occurred three days following stent placement, successfully managed with anticoagulation. The authors recommend this procedure as a way to relieve the anasarca and ascites associated with this debilitating end-stage syndrome.

COMMENTARY

This study draws attention to IVC syndrome, a condition characterized by ascites and bilateral lower extremity edema. Stenting the retrohepatic IVC will, at least partially, relieve the IVC pressure gradient caused by external tumor compression and provide symptomatic relief by improving lower extremity edema, improving ascites, and inducing weight loss.

Several points can be made about this article. Apparently, more than one stent may be required for long-segment compression although the exact number of stents used here is unclear. Post stent IVC pressure gradients were improved in all patients although 7 of 28 (25%) post stent IVC pressures were 8 mmHg. This persistent moderate IVC pressure elevation would not be surprising given the noncompressible nature of hepatic lesions. It seems likely that IVC stents remained patent given the lack of clinical deterioration.

Duplex confirmation is difficult in retrohepatic IVC and followup venocavography is hard to justify in this patient population with very short life expectancy. The authors state that patients may have a dramatic reduction in ascites post stenting although no abdominal girth or direct measurements are given. It is not clear why ascites would be relieved by a stent in this position (perhaps abdominal wall edema was relieved).

The choice of stent seems appropriate: self-expanding, wide diameter, and large interstices. However, we have used the Gianturco self-expanding Z-stent infrequently in favor of the Wallstent. The cost of the Z-stent ranges from $341 to $434 for a single double-body stent, relatively less expensive than either the Wallstent or the Palmaz stent. Clearly, one would not expect this procedure to impact survival.

Furui et al. document their experience in 39 patients with SVC (16) or IVC (23) stent placement for malignancy.1 The Gianturco expandable metallic stent was used in each case, usually a single assembly of tandem (double body) stents (30 patients). Long lesions or lesions of the IVC and both iliac veins necessitated placement of two or three such assemblies. All IVC stent patients improved symptomatically although 7 of 16 (44%) post placement venograms showed residual lumen stenosis, mostly elliptical in appearance.

The authors comment that moderate residual stenosis is not a problem as long as there is good flow through the stented lumen. In some cases, delayed expansion of the stent may occur. The large diameter of the Gianturco stent made it suitable for the IVC or the SVC lumen (15 to 30 mm). Noted was the relatively large interstices of the Gianturco stent may be important to prevent occlusion of the caval tributary veins. Among IVC stent patients, autopsy was performed in four at one to three months following stent placement. The IVC and hepatic veins bridged by the stents were patent. The authors also note that they do not perform balloon dilation prior to stent placement in the IVC because, although the IVC is easily opened by balloon inflation, occlusion recurs immediately after deflation. In three IVC patients, the stent partially lodged in the right atrium. EKGs showed no abnormalities.

The placement of IVC stents for IVC syndrome met with good symptomatic relief and few complications in both series. Although patient survival is short, this palliative measure seems appropriate in this unfortunate group. vdcor136

REFERENCE

1. Furui S, Sawada S, Kuramoto K, et al. Gianturco stent placement in malignant caval obstruction. Analysis of factors for predicting the outcome. Radiology 1995; 195:147-52.

SUGGESTED READING

1. Furui S, Sawada S, Irie T, et al. Hepatic inferior vena cava obstruction: Treatment of two types with Gianturco expandable metallic stents. Radiology 1990; 176:665-70.

2. Dondelinger RF, Goffette P, Kurdziel JC, Roche A. Expandable metal stents for stenoses of the vena cava and large veins. Sem in Interv Radiol 1991; 8:4.

3. Nicholson AA, Ettles DF, Arnold A, Greenstone M, Dyet JF. Treatment of malignant superior vena cava obstruction: Metal stents or radiation therapy. JVIR 1997; 8(5):781-88.

4. Kim JK, Park SJ, Kim YH, et al. Experimental study of self-expandable metallic inferior vena cava stent crossing the renal vein in rabbits: Radiologic/pathologic correlation. Invest Radiol 1996; 31(6):311-15.




MAY-THURNER SYNDROME: THREE PATIENTS TREATED WITH CATHETER-DIRECTED THROMBOLYSIS AND STENT PLACEMENT
 Henderson AM, McIntyre KE, Hunter GC, Walser E, Schaper D.
Vasc Surg 1998; 32(5):439-46

ABSTRACT AND COMMENTARY BY:
Bo Eklof, M.D.
Straub Hospital and Clinic
Honolulu, Hawaii

The authors report three cases of left common iliac vein deep venous thrombosis caused by iliac vein compression syndrome. Catheter-directed thrombolysis using urokinase was performed successfully, allowing visualization of the lesions treated with balloon venoplasty and stenting followed by oral anticoagulation. All three patients improved with patent iliofemoral veins by duplex scan at eight to twelve months of followup. The authors conclude that catheter-directed thrombolysis of left iliac vein thrombosis may identify patients with May-Thurner syndrome. This may occur more commonly than previously reported. They also conclude that May-Thurner syndrome may be effectively treated nonoperatively by balloon angioplasty and stenting of the stenotic segment. Finally they conclude that the long-term results of the role of warfarin treatment are currently unknown.

COMMENTARY

Compression of the left common iliac vein by the right common iliac artery is a very common finding and the cause for the preponderance of left-sided iliofemoral deep venous thrombosis.

In a study of 430 autopsies, May and Thurner (1957) noted changes in 19% at the junction of the left common iliac vein with the inferior vena cava which they called venous spurs. They described three varieties: The lateral spur (14%), the central spur (4%), and partial obliteration (1%). Their histological studies indicated that the spurs were produced by chronic irritation of the intima with endothelial proliferation and that the spurs were neither congenital or postthrombotic. The position of the left common iliac vein between the pulsating right common iliac artery and the hard surface of the last lumbar vertebra was the cause.

Cockett and Thomas (1965) described the iliac compression syndrome presenting as two clinical manifestations: An acute phase with iliofemoral deep venous thrombosis (primary iliofemoral deep venous thrombosis) and a chronic phase with swelling and aching of the leg, venous claudication, a tendency for recurrent deep venous thrombosis, pigmentation, and chronic ulceration.

The hemodynamic consequences of iliac vein obstruction are important with marked pelvic collaterals and dilatation of the ascending lumbar vein. The most important femoral vein pressure indicators for noncompensated iliac vein obstruction are pressure elevation after exercise, pressure difference after exercise, and normalization time after exercise. In the majority of cases, treatment is conservative using a good compression stocking. Surgery is indicated when conservative treatment fails or if primary iliofemoral deep venous thrombosis develops.

The logical treatment for the noncompensated iliac vein compression syndrome has been to abolish the compression and remove the spurs. A large variety of operative techniques have been suggested. In our book entitled Controversies in the Management of Venous Disorders (1989)1 we suggested the following treatment: Exploration of the left femoral vein, introduction of a venoscope into the left iliac vein, removal of spurs and old thrombi under direct vision with the laser, intraoperative balloon dilation of the compressed area, introduction of an intraluminal stent to abolish compression and avoid restenosis, the establishment of a distal arteriovenous fistula to increase flow and enhance endothelial healing, and then final closure of the arteriovenous fistula percutaneously with a detachable balloon after six weeks.

The plethora of surgical techniques described during the 1970s and 1980s speaks for itself. None was proven effective. Our suggestion ten years ago of angioplasty and stenting has been implemented. This is done much more elegantly now using percutaneous techniques. Several series of venous angioplasty and stenting have now been reported and we now wait for the long-term results. ivdfekl

REFERENCE

1. Eklof B, Juhan C. Venous compression syndromes caused by anatomical anomalies. In: Eklof B, Gjores JE, Thulesius O, Bergqvist D (eds). Controversies in the Management of Venous Disorders . London, Butterworth 1989; 291-307.


EDITOR'S NOTE

 In the March 1999 issue of the Venous Digest, Michel Perrin created an excellent summary and commentary on a presentation from the International Journal of Angiology (Lurie F, Makarova NP), an article entitled Clinical Dynamics of Varicose Disease in Patients with High Degree of Venous During Conservative Treatment and After Surgery: A 7-Year Followup .

In the third paragraph of that summary, Perrin correctly designated that the study was done after LSV stripping. This was taken by our editorial office to mean lesser saphenous vein. This was because in our style sheets, we use the term greater saphenous vein (GSV) in order to avoid the confusion that occurs when LSV is designated. LSV, of course, could be long saphenous vein or lesser saphenous vein.

We could encourage leading phlebologists, vascular surgeons, general surgeons, and other interested parties to use the terms greater saphenous vein (GSV) and lesser saphenous vein (LSV) and abandon the term long saphenous vein. There is enough confusion in phlebology without adding to it by misuse of terms.




ENDOSCOPIC PERFORATOR VEIN DIVISION WITH ABLATION OF SUPERFICIAL REFLUX IMPROVES VENOUS HEMODYNAMICS
 Rhodes J, Gloviczki P, Canton L, Heaser T, Rooke T.
J Vasc Surg 1998; 28:839-47

ABSTRACT AND COMMENTARY BY:
Prof. Hugo Partsch
Wilhelminenspital der Stadt Wien
Dermatologische Abteilung
Wien, Austria

A total of 26 patients (18 women, 8 men) with a mean age of 50 years had 31 subfascial endoscopic perforator vein procedures. Twelve limbs had active ulcers, 13 had healed ulceration, 5 demonstrated skin changes of pigmentation, eczema, or lipodermatosclerosis, and only one had edema alone. Reflux was predominant in 29 limbs, chronic venous occlusion was a major problem in two limbs which also had an element of reflux. Concomitant saphenous vein stripping was done in 22 limbs and high ligation without stripping in two. Six limbs had perforator interruption in combination with avulsion of varicosities and one limb had perforator interruption alone. The operations improved calf muscle pump function, reduced venous incompetence, and produced good mid-term clinical results. The authors concluded that the study supports adding the SEPS procedure to ablation of superficial reflux in patients with advanced chronic venous insufficiency.

COMMENTARY

This important paper describes thoroughly the clinical and hemodynamic outcome of endoscopic perforator vein division together with paratibial fasciotomy in 24 limbs in which high ligation and saphenous vein stripping was performed in 22 and high ligation alone in two. In seven limbs, subfascial endoscopic perforator surgery (SEPS) was done. Avulsion of varicose veins was done in six and SEPS alone in one.

The question remains as to whether the results would be as good if only the saphenous reflux had been attacked without perforator surgery. Since SEPS alone was done in only one limb, no conclusions may be drawn concerning the effect exerted by isolated removal of incompetent perforators. We look forward to seeing studies in which a control group is included. It would be interesting to compare the results of SEPS with conventional methods such as the Cockett procedure or avulsion of perforators with hook instruments.

It is remarkable that the introduction of new endoscopic devices again brings up old controversies regarding the pathophysiological importance of incompetent perforators. A clear indication for the division of perforators is still lacking. Most of our colleagues simply follow the old surgical rule which says to take out what should not be there. Sometimes the enthusiasm for ingenious new techniques prevails so strongly that they are utilized wherever possible.

Future work should be based on the results of important previous investigations.1 It will be necessary to define clear indications for SEPS in superficial and/or deep venous insufficiency, performed together with saphenous vein surgery or as an isolated procedure. ivdfpar

REFERENCE

1. Bjordal R, May R, Partsch H, Staubesand J (Eds). Perforating Veins. Urban & Schwarzenberg, Munich, Vienna, Baltimore, 1981.




CLASSIC VERSUS ENDOSCOPIC PERFORATING VEIN SURGERY: A RETROSPECTIVE STUDY
 Lacroix H, Smeets A, Nevelsteen A, Suy R
Acta Chir Belg 1998; 98:71-75

ABSTRACT AND COMMENTARY BY:
Harold Welch, MD
Department of Vascular Surgery, Lahey Clinic
Burlington, Massachusetts

This retrospective, non-randomized study compared results of three contemporaneously distinct techniques of perforating vein surgery. The Felder technique was performed 29 times (25 patients) from 1990 to 1994. Use of a mediastinoscope for subfascial endoscopic surgery was performed 19 times (17 patients) in 1995. Laparoscopic instruments, thigh tourniquet, and gas insufflation was used in 57 procedures (55 patients) from 1996 to 1997. Patients were categorized into Groups F, M, and L, respectively.

Indications for surgery included varicose veins with and without ankle edema, lipodermatosclerosis, and active or healed ulcer. Ulcer history was present in only 23 to 31% of the patients (not statistically significant) while 47% of patients in Group M had only varicose veins. Concomitant ipsilateral superficial venous system procedures were performed in 22, 15, and 52 limbs, respectively. Duplex examination and/or phlebography was done in most limbs preoperatively. Information concerning obstruction and reflux was mentioned for each group although this did not factor into the results.

Followup was done by telephone interview. Patients were questioned about the length of convalescence, their satisfaction with the procedure, use of elastic stockings, and ulcer healing/recurrence. Length of followup was not stated.

The results were predictable. Although more perforators were interrupted on average by the Felder technique, elimination of two outliers (12 and 15 interrupted perforators) gave a mean for Group F of 2.9, less than Group L (mean 3.8 perforators interrupted). The mean hospital stay for Group F was 3.5 days, significantly longer than Group M (1.9 days) and Group L (1.6 days). Patients in Group F were operated on nearly ten years ago which may account, in part, for the longer stay. The complication rate among the three groups was statistically similar, ranging from 26 to 31%. Patients judged their mean convalescent time to be 8.7 weeks in Group F, significantly longer than Group M (4.1 weeks) and Group L (3.7 weeks).

COMMENTARY

Surgical treatment of incompetent perforating veins continues to be controversial and kaleidoscopic. From Linton's standard surgical approach to the minimally invasive techniques of Hauer, O'Donnell, and Gloviczki, the goal is to heal the venous skin maladies with minimal complications and resumption of a productive life. The current authors, among others, have shown this to be a reasonable objective.

The long-term effectiveness of such surgery remains arguable. Lacroix and his associates recognized the shortcomings inherent in their study (lack of randomization, short and variable followup, contemporaneously different techniques, and reliance on the memory of the patients). However, they have also demonstrated that newer, minimally invasive surgery is, in fact, progress. vdwel074




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


First Experimental Study of Carbon Dioxide Digital Subtraction Lymphangiography
Dimakakos PB, Papasavva M, Stefanopoulos T, et al.
Eur J Plast Surg 1997; 20:132-35

In this animal study, very satisfactory lymphangiograms were obtained using a medium which is not nephrotoxic and is totally nonallergenic. This might have clinical application.


Elastic Compression Stockings: Durability of Pressure in Daily Practice
Veraart JCJM, Daamen E, de Vet HCW, Neumann HAM
VASA 1997; 26: 282-86

This carefully done study concludes that the most frequently used class II stockings last sufficiently that only three new stockings each year are necessary to insure effective functioning.


Low-Molecular-Weight Heparin for Immediate Management of Thromboembolic Disease in Pregnancy
Thomson AJ, Walker ID, Greer IA.
Lancet 1998; 352:1904

Subcutaneous low-molecular-weight heparin appears to have an advantage over unfractionated heparin for treatment of venous thromboembolism in pregnancy.