VD611R

THE POSTTHROMBOTIC SYNDROME IN RELATION TO VENOUS HEMODYNAMICS AS MEASURED MEANS OF DUPLEX SCANNING AND STRAIN-GAUGE PLETHYSMOGRAPHY
Haenen JH, Janssen MCH, van Langen H, et al.
J Vasc Surg 1999; 29:1071-76

ABSTRACT AND COMMENTARY BY:
Nicos Labropoulos, MD
Section of Peripheral Vascular Surgery
Loyola University Medical Center
Maywood, Illinois

A total of 82 patients out of 252 with documented past deep venous thrombosis (DVT) on phlebography were examined by duplex scanning for reflux and anatomic obstruction and measured by strain-gauge plethysmography for venous outflow resistance 7 to 13 years later (mean 10 years). None of the patients had an active ulcer, 28 had some degree of skin damage, 32 were in chronic venous insufficiency classes 1 to 3 by CEAP classification, and 22 had no signs or symptoms of chronic venous insufficiency.

Venous resistance was abnormal in 11% of patients but it was not significantly higher in patients with severe postthrombotic syndrome. Reflux in the superficial femoral and popliteal veins had significant correlation with the severity of chronic venous insufficiency but this was not observed in patients with saphenous reflux. A combination of superficial and deep venous reflux was more common in patients with severe symptoms. Age and reflux were strongly associated with the presence of postthrombotic syndrome.

COMMENTARY

The natural history of deep venous thrombosis has been described in several studies.1-4 It has been demonstrated that DVT leads to chronic obstruction, valvular damage and reflux. In a prospective study with serial followup of patients with proximal DVT, reflux developed in 69% at one year.1 A combination of reflux and obstruction had the worst prognosis for developing skin damage compared to reflux or obstruction alone.5

The current study offers new information not only because it evaluated clinical signs and symptoms but also used duplex scanning and strain-gauge plethysmography to document reflux and obstruction. The prevalence of severe signs and symptoms was comparable to that reported by Franzeck in a 12-year followup study.6 A prospective study by Meissner showed that in patients with DVT, the determinants of clinical severity include the extent of reflux, presence of persistent popliteal obstruction, and rate of recanalization.7

A combination of deep and superficial reflux was more common in patients with severe symptoms. Several papers have shown that more systems are involved with worsening of chronic venous insufficiency.8-10 Combined reflux in superficial perforator and deep veins is found in about one-third of patients with skin damage, and involvement of the superficial and deep veins is seen in about 50%.11 Again, the current study showed that venous reflux is more important than obstruction in the development of symptoms since venous outflow obstruction was detected in only 11% of patients. Obstruction was not more prevalent in patients with severe symptoms. However, the significance of the obstruction was not measured under reactive hyperemia or by using venous pressure measurements as has been previously described.12,13 Furthermore, the clinical presentation of patients prior to DVT and the incidence of re-thrombosis was not mentioned in this study.

Re-thrombosis occurs in 24.6% (95% CI, 19.6% to 29.7%) at five years and 30.3% (95% CI, 23.6% to 37%) at eight years.14 The development of ipsilateral recurrent DVT had a significant relation with the risk for postthrombotic symptoms (haz.rat.6.4; 95% CI, 3.1 to 13.3).

Overall, this is a great study with long-term followup which adds some new information to the literature and reinforces the results of other recent studies. vdlab291

REFERENCES

1. Markel A, Manzo RA, Bergelin RO, Strandness DE, Jr. Valvular reflux after deep vein thrombosis: Incidence and time of recurrence. J Vasc Surg 1992; 15:377-82.

2. Meissner MH, Manzo RA, Bergelin RO, Markel A, Strandness DE, Jr. Deep venous insufficiency: The relationship between lysis and subsequent reflux. J Vasc Surg 1993; 18:596-605.

3. van Ramshorst B, van Bemmelen PS, Hoeneveld H, Eikelboom BC. The development of valvular incompetence after deep vein thrombosis: A followup study with duplex scanning. J Vasc Surg 1994; 19:1059-66.

4. Labropoulos N, Leon M, Nicolaides AN, et al. Venous reflux in patients with previous deep venous thrombosis: Correlation with ulceration and other symptoms. J Vasc Surg 1994; 20:20-26.

5. Johnson BF, Manzo RA, Bergelin RO, Strandness DE Jr. Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an episode of lower limb deep venous thrombosis: A one- to six-year followup. J Vasc Surg 1995; 21:307-12.

6. Franzeck UK, Schalch I, Jager KA, Schneider E, Grimm J, Bollinger A. Prospective 12-year followup study of clinical and hemodynamic sequelae after deep vein thrombosis in low-risk patients (Zurich study). Circulation 1996; 93:74-79.

7. Meissner MH, Caps MT, Zierler BK et al. Determinants of chronic venous disease after acute deep venous thrombosis. J Vasc Surg 1998; 28:826-33.

8. Labropoulos N, Leon M, Geroulakos G et al. Venous hemodynamic abnormalities in patients with leg ulceration. Am J Surg 1995; 169:572-74.

9. Myers KA, Ziegenbein RW, Zeng GH, Mathews PG. Duplex ultrasonography scanning for chronic venous disease: Patterns of reflux. J Vasc Surg 1995; 21:605-12.

10. Labropoulos N, Delis K, Nicolaides AN et al. The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency. J Vasc Surg 1996; 23:504-10.

11. Labropoulos N. Clinical correlation to various patterns of reflux. J Vasc Surg 1997; 31:242-48.

12. Neglen P, Raju S. Detection of outflow obstruction in chronic venous insufficiency. J Vasc Surg 1993; 17:583-89.

13. Labropoulos N, Volteas N, Leon M et al. The role of venous outflow obstruction in patients with chronic venous dysfunction. Arch Surg 1997; 132:46-51.

14. Prandoni P, Lensing AW, Cogo A et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 1996; 125:1-7.

VENOUS INSUFFICIENCY OF THE LOWER LIMBS AND WORKING CONDITIONS
Sobaszek A, Frimat P, Tiberguent A et al.
Phlebology 1998; 13:133-41

ABSTRACT AND COMMENTARY BY:
Mark D. Iafrati, MD, Maj. USAF MC
Chief, Vascular Surgery
Malcolm Grow Medical Center
Andrews Air Force Base, Maryland

The authors set out to determine the prevalence of venous insufficiency in a population of women working in the health and social sectors of France. More significantly, they also evaluated the relative contributions of different occupational and personal risk factors. A total of 1823 women were evaluated in a descriptive multicenter, cross-sectional study from January to September 1995. These women were selected from four employment sectors within healthcare facilities: Operating rooms (522), hospital laundries (136), daycare nurseries (483), and secretaries (682).

The study included a physical examination and medical questionnaire summarizing personal and family history, job characteristics, work and living conditions, and cardiovascular and venous symptoms within the previous 12 months. An occupational health physician summarized the characteristics of working positions and displacements and completed a job description form for each activity sector. As a measure of working conditions, a meteorological form was completed once during each season at each site. Environmental measures were recorded on the same date at each center and included temperature, humidity, air speed, and the presence of air conditioning. Venous insufficiency was classified as minor or advanced.

The four study populations were similar in terms of marital status, number of persons and children living at home, menopause, and estrogen replacement therapy. Of particular note is the extremely high prevalence of venous disease reported by patients. This ranged from 71% for office workers to 84% for operating room and laundry workers. Also striking was the 55% incidence of treatment for venous disease in the last year with 63% of operating room personnel having received at least one treatment. Laundry workers were significantly larger individuals than other workers with a body mass index double that of any other group. The childcare workers were younger and had fewer pregnancies.

The operating room and laundry populations carried heavier loads on the job and spent significantly more of the workday in standing positions, especially without displacement. The childcare staff spent most of the day kneeling or squatting, and office staff worked in the sitting position. The laundry and operating room personnel were subjected to the greatest heat, especially in the summer. The laundry and childcare workers were subjected to the greatest humidity.

COMMENTARY

Using a multivariate analysis, the authors attempt to discriminate the influence of multiple risk factors on the development and severity of venous disease. They report that the length of job service was the main factor involved in the severity of disease and that this effect was independent of age. Other independent factors included the number of pregnancies, obesity, high temperature in the work place, carrying heavy loads, and working position. These data are in accordance with much of the contemporary literature which has established the influence of family history (especially maternal) and obesity on the development of venous disease. The influence of maternity has also been well established with a third pregnancy increasing the risk of functional disorders and a fourth pregnancy relating to the presence of varicose veins.

The authors suggest that working conditions including static posture, high temperature, and carrying heavy loads should be added to the list of risk factors in the development of venous disease. They recommend a more vigilant approach to the prevention and management of venous diseases for people exposed to these work and environmental conditions.

While the authors have made a valuable contribution to our understanding of the influence of environmental working conditions on the development of venous disease, I believe their results must be interpreted with some skepticism. The confounding effects of marked obesity in laundry workers, the young age and high incidence of nulliparity in daycare workers, and the overall extremely high prevalence of venous disease (71% to 84%) combine to limit the analysis. Further, the classification of heavy lifting seems ambiguous with operating room personnel designated as heavy lifters based on several patient transfers per day.

Further study is required to better delineate the effects of workplace environmental factors on the development and severity of venous disease. vdiaf291

MANAGEMENT OF UPPER EXTREMITY CENTRAL VENOUS OBSTRUCTION USING INTERVENTIONAL RADIOLOGY
Kalman Pg, Lindsay TF, Clarke K, Sniderman KW, Vanderburgh L.
Ann Vasc Surg 1998; 12:202-206

COMMENTARY BY:
Mehmet Kurtoglu
Istanbul, Turkey

These authors have attempted to determine the clinical condition of patient limbs with upper extremity venous thrombosis after interventional radiologic management. Up until 1995, there was no data to prove that lytic therapy was superior to heparin in treatment of upper extremity deep venous thrombosis. Interventional radiologic management began recently and there is no randomized study which proves superiority of thrombolytic treatment in the long term. Upper extremity venous thrombosis has been treated successfully with heparin but there is a theoretical advantage to achieving patency of the subclavian vein. Virtually all investigators have come to the conclusion that extrinsic compression producing intrinsic vein abnormalities needs attention. Extrinsic compression is conventionally treated by first rib resection and the intrinsic residual stenosis has been addressed by first rib resection, endovenectomy, patch angioplasty, and/or jugular vein transposition.1-3

Studies such as this one should prove that less invasive interventional radiologic treatment is at least as good as surgical intervention. Unfortunately, variability of patient presentations, few patients treated, and no standardized treatment algorithm makes the present data less useful. The followup was clinical in 24%, objective with duplex confirmation in 34%, and objective with phlebography in 27%. All three types of treatment modalities, including thrombolysis, percutaneous angioplasty, and stent were used in 40 patients (59 veins). In the 10% of cases which were primarily Paget-Schroetter disease, first rib resection was done. Details of followup management of these six cases are not available and re-thrombosis may have occurred. I note a single dose of 5000 units of heparin was given and oral anticoagulation was not continued for at least three months.

In general, others agree that angioplasty should be withheld following urokinase treatment until extrinsic compression has been relieved. Stents should not be used following lytic therapy alone as stent compression will occur in the absence of venous decompression. Once surgical first rib resection and thrombolysis are complete, angioplasty can be performed for persistent stenosis if the patient remains symptomatic. Up to now, stents have not been shown to be of proven value following angioplasty. On the other hand, stents can be complicated because of rethrombosis and their presence makes restorative operations more difficult.4

In summary, I completely agree with the authors that these techniques are useful adjuvant for high-risk patients requiring palliation from central ventral hypertension when surgery is not an attractive option. Unfortunately, since there are few cases, the data presented in this report does not strongly support this conclusion. In the present report, it appears that patients treated nonoperatively seem to do as well as those in whom interventional radiologic management or rib resection was done. Heparin followed by long-term anticoagulation with Coumadin is also a reasonable option. When symptoms are severe, repeat phlebographic assessment at six to eight weeks may be done in order that venous repair can be considered. Such venous repair could consist of juguloaxillary vein transposition or other method. Experience as reported in the literature suggests that almost all primary non-catheter-related upper extremity venous thrombosis is caused by thoracic outlet compression and that first rib resection should be considered after lytic therapy successfully opens the subclavian vein. At least 10% of the authors' cases could be managed in this logic. ivdfkur1

REFERENCES

1. Molina JE. Need for emergency treatment in subclavian vein effort thrombosis. J Am Coll Surg 1995; 181:414-20.

2. Molina JE. A new surgical approach to the innominate and subclavian vein. J Vasc Surg 1998; 27:676-81.

3. Machleder HL. Evaluation of a new treatment strategy for Paget-Schroetter syndrome. 1993; 17:305-17.

4. Sanders RJ. Management of effort thrombosis and subclavian vein obstruction. Presened at 25th Annual Symposium, Montefiore Medical Center, New York, 1998.

SUPERFICIAL VEIN THROMBOSIS OF THE LOWER LIMBS: INFLUENCE OF FACTOR V LEIDEN, FACTOR II G20210A AND OVERWEIGHT
de Moerloose P, Wutschert R, Heinzmann M, Perneger T, Reber G, Bounameaux H
Thromb Haemost 1998; 80:239-41

COMMENTARY BY:
Prof. Renate Koppensteiner
Z�rich, Switzerland

In 112 patients with superficial vein thrombosis (SVT) of the lower limbs, the prevalence of the two most common thrombophilic abnormalities, factor V Leiden and factor II G20210A, were investigated. A total of 180 healthy donors served as controls. Factor V Leiden was present in 14.3% of the SVT patients and in 6.1% of the controls. Factor II G20210A was found in 3.6% of patients and in 1.1% of controls. A body mass index (BMI) 28 kg/m2 was associated with SVT. After adjustment for BMI, the association between factor V Leiden and SVT was no longer statistically significant. Among SVT patients, the presence of factor V Leiden was independently associated with the absence of varicose veins.

COMMENTARY

The association between inherited thrombophilia and deep venous thrombosis/venous thromboembolism is well established. However, data about the prevalence of thrombophilic factors in patients with SVT are rare. SVT is a common disease, most frequently seen in patients with varicose veins (90%). SVT on non-varicose veins might be secondary to other diseases such as malignancy, Buerger disease, and mixed connective tissue disease. Further, SVT has been reported in patients with inherited thrombophilic defects like protein S or protein C deficiency.

Data of the present study show that the prevalence of factor V Leiden is higher in patients with SVT than in controls. Further, a BMI 28 kg/m2 is associated with subclavian vein thrombosis. Multivariate analysis suggests that the prevalence of factor V Leiden is higher in patients having non-varicose veins than in patients having BMI < 28 kg/m2. The conclusion is drawn that factor V Leiden and obesity seem to predispose to SVT.

Until now, it has been unusual to perform screening tests for inherited thrombophilia in patients with SVT. Since SVT is such a common disease, this would have a large impact on community resources without positive consequences on the therapeutic regimen in these patients. The authors regard their results as preliminary only and plan confirmation in larger studies. Nevertheless, attention should be drawn to patients with SVT on non-varicose veins without obesity. Among these, a thrombophilic disorder might be one of several causes of SVT and should be considered. ivdfkop1

REFERENCES

1. Feuerstein W. Oberfl�chliche beinvenenthrombosen, varikophlebitis. In: Partsch H (ed). Phlebologiekurs . Zyma GmbH, M�nchen, 1987.

APC RESISTANCE IS A RISK FACTOR FOR POSTOPERATIVE THROMBOEMBOLISM IN ELECTIVE REPLACEMENT OF THE HIP OR KNEE: A PROSPECTIVE STUDY
Lindahl TL, Lundahl TH, Nilsson L, Andersson CA
Thromb Haemost 1999; 81:18-21

ABSTRACT AND COMMENTARY BY:
Prof. dr. hab. med. Mieczyslaw Szotstek
Warszawa, Poland

This study assesses the prevalence of APC resistance in a general population and its clinical significance in patients undergoing surgery with a high risk for thromboembolic complications.

A total of 645 consecutive patients were selected from three hospitals in southern Sweden. An analysis for APC resistance was done and thromboprophylaxis with low-molecular-weight heparin accomplished in all patients throughout their hospitalization period. Endpoints for the study included clinical thromboembolism during the first three postoperative months as well as a study of phlebography, ultrasonography, or pulmonary scintigraphy when requested by clinicians according to their existing routines. A thromboembolic complication was recorded in 20 patients (3.1%). Proximal venous thrombi occurred in 50% of these and only one (0.3%) of the patients had a verified pulmonary embolism. APC resistance was found in 14.1% of patients and 9.9% of these experienced postoperative thromboembolism. This compared with 2% of the patients without APC resistance (p < 0.0007).

It is concluded that APC resistance is a frequent risk factor for symptomatic postoperative deep venous thrombosis.

COMMENTARY

Protein C, a vitamin K-dependent plasma protein, is the key factor in a physiologically active anticoagulant system. After its activation on the surface of endothelial cells by a complex of thrombin with thrombomodulin, activated protein C inhibits coagulation by selectively degrading coagulation factors Va and VIIIa.1

Young people with thrombosis frequently have a family history of thrombosis, indicating the importance of genetic factors.2 Svensson described a relationship between familial thrombosis and an inherited defect in the anticoagulant response to APC that he termed APC resistance.1 He and his colleagues found APC resistance to be highly prevalent in patients with thrombosis and to be much more common than other genetic defects which were known to occur in these patients.

Deep vein thrombosis after total hip replacement is very prevalent, in the range of 50 to 60%. Risk for deep vein thrombosis is more protracted after hip surgery than after general surgery. The surgical technique, which kinks the femoral vein, seems to stimulate deep vein thrombosis. Throwbridge showed that patients undergoing total hip arthroplasty have a 10.5% incidence of deep vein thrombosis during the first six weeks after surgery.3 Thus, the thrombogenic period may be prolonged in some patients. Risk of fatal pulmonary embolism continues for at least one month after surgery. In patients with trauma, the risk may last even longer. The high thromboembolism rate is considerably reduced with subcutaneous injections of low-molecular-weight heparin during initial hospitalization. The question is how long this prophylaxis should be pursued.

The authors' suggestion to use low-molecular-weight heparin only during hospitalization is not accepted by others. Some reports extend the risk of thromboembolism for one month post total hip surgery and prolong the prophylaxis up to six weeks using low-molecular-weight heparin.3 ivdfszo1

REFERENCES

1. Svensson PJ, Dahlback B. Resistance to activated protein C as basis for venous thrombosis. N Engl J Med 1994; 330:517-22.

2. Raider PM, et al. Mutation of the gene codine for coagulation factor V and the risk of myocardial infarction, stroke, venous thrombosis in apparently healthy young men. N Engl J Med 1995; 332:912-17.

3. Bergqvist D, et al. Low-molecular-weight heparin as prophylaxis against venous thromboembolism after total hip replacwment. N Engl J Med 1996; 335:696-700.

VENOUS GANGRENE OF THE UPPER EXTREMITY
Kaufman BR, Zoldos J, Bentz M, Nystrom NA
Ann Plast Surg 1998; 40:370-77

ABSTRACT AND COMMENTARY BY:
John H. Scurr, FRCS
Senior Lecturer, Consultant Surgeon
Middlesex and University College Hospital
London, United Kingdom

Phlegmasia cerulea dolens and venous gangrene are rare conditions associated with both physiological and haematological abnormalities. This paper presents six patients with extensive upper limb thrombosis and reviews the literature relating to presentation and management of this condition. Early recognition of the clinical symptoms from simple edema to edema with cyanosis and then impending gangrene are important. The authors found no value in using computed tomography or MRI but relied on duplex ultrasound scanning of the veins. They stressed the importance of underlying hematological abnormalities, a pre-existing thrombophilia, malignancy, or cardiac conditions.

With appropriate evaluation and anticoagulation, 50% of patients treated before the onset of substantial gangrene were successful. Despite intervention, however, morbidity and mortality remain high.

COMMENTARY

This is an extremely rare condition, usually associated with pre-terminal conditions. Early diagnosis before gangrenous changes are apparent really offers the only hope of effective treatment. Thrombectomy, anticoagulants, and fibrinolytic treatment are the mainstays of treatment. So often, these conditions are associated with such severe underlying medical problems, terminal malignancy, severe cardiac problems, or complex hematologic hypercoagulable states that even effective treatment is short lived. The authors provide a good review of a very rare condition. ivdfscu

OUTPATIENT TREATMENT OF ACUTE DEEP VENOUS THROMBOSIS
Mattiasson I, Berntorp E, Bornhov S, Lagerstedt C, Lethagen S, Persson J, Timberg I, Torstensson I.
Int Angiol 1998; 17:146-50

COMMENTARY BY:
Peter Conrad, FRCS, FRCS(Ed), FRACS, FACS(US)
Sydney, Australia

This is a multicenter study from Sweden involving six hospitals where 523 consecutive patients over age 18 with deep venous thrombosis (DVT) diagnosed by venogram or duplex scan were assessed. Outpatient treatment was instituted in 38% with low-molecular-weight heparin in the form of enoxaparin 1 mg/kg body weight subcutaneously twice daily, tinzaparin 175 mg/kg body weight subcutaneously once daily, or dalteparin 200 IU/kg body weight subcutaneously once daily. Oral anticoagulant therapy was started and monitored from day one and the low-molecular-weight heparin was discontinued when the prothrombin index was in the therapeutic range. An additional 8% were initially treated in the hospital (median two days) and then transferred to the outpatient program.

Exclusions (54%) were due to pulmonary embolus, phlegmasia, iliac vein thrombosis, vena cava thrombosis, intracerebral bleed in the preceding six months, gastrointestinal bleed or hematuria in the preceding one month, major surgery in the preceding two weeks, hypertension with grade 3 or 4 fundal changes, renal failure with serum creatinine greater than 170 mmol/l, pregnancy, or inability to cooperate due to dementia or drug abuse. Patients were able to ambulate at will and there was no laboratory monitoring of anti-factor Xa activity.

Results over three months of those treated strictly as outpatients or transferred from hospital to outpatient treatment showed: 1) median duration of low-molecular-weight heparin treatment of five days, 2) three patients hospitalized for minor complications with full recovery, and 3) after low-molecular-weight heparin treatment, there were six cases of bleeding, no proven cases of pulmonary embolus, and one case of distal progression of thrombus. The authors conclude that uncomplicated deep vein thrombosis can be safely treated on an outpatient basis in 50% of cases.

COMMENTARY

This is yet another study agreeing with the emerging literature that a large proportion of patients with acute deep vein thrombosis can be safely and effectively treated as outpatients usually by subcutaneous injection of low-molecular-weight heparin twice daily. This is continued until the simultaneously given oral anticoagulants achieve a therapeutic level as measured by the prothrombin index. This is a great advance from the days of strict bedrest and intravenous heparin in a hospital setting.

It is now accepted that most cases of low-molecular-weight heparin treatment do not need monitoring. This is fortunate since LMWH levels can be monitored only by measuring anti-Xa units which is expensive and time consuming.

Low-molecular-weight heparins have a long half-life. Therefore, there is now a move to once-daily dose regimens in higher doses. For example, enoxaparin is now given as a 1.5 mg/kg once daily rather than 1 mg/kg twice daily. We anticipate that future studies will support the safety and efficacy of this.

Importantly, low-molecular-weight heparins do not cross the placenta in significant amounts nor do they pass into breast milk. Therefore, they are deemed safe to use during pregnancy and lactation.

It is surprising that iliac vein thrombosis was excluded in this study since previous major studies have shown that low-molecular-weight heparin treatment can be given for iliofemoral thrombosis cases without increasing the mortality or morbidity.

Finally, one of the unanswered questions to be addressed by future studies using duplex ultrasound and plethysmography is whether there is a difference in the long-term physiology of the deep veins. The extent of recanalization, the status of the valves, and the extent of residual obstruction or incompetence of the deep veins should be compared in a long-term study of the two methods. ivdfcon2

SYMPTOMATIC DEEP VENOUS THROMBOSIS OF THE LOWER LIMB
Giannoukas AD, Fatouros M, Batsis H, Mitsis M, Matsagas M, Koulouras V, Tsampoulas C, Kappas M, Cassioumis A.
Int Angiol 1998; 17:151-54

COMMENTARY BY:
Prof. Lars Norgren
Lund, Sweden

The authors present a retrospective study of 187 symptomatic patients with a suspected deep venous thrombosis (DVT). Patients were either surgical or referred to the authors' surgical unit. Symptoms had been present for less than six days. An ascending venography was performed within 48 hours after clinical evaluation. A total of 76 patients (77 limbs) had positive venograms for DVT. There was an over-representation of females (64%). In 38% of limbs, the thrombosis was postoperative and patients came from various surgical specialties, except orthopedic surgery.

In 46% of limbs, the thrombosis was restricted to calf veins without any difference between surgical and nonsurgical patients. An isolated proximal thrombosis was uncommon (10% and 6% respectively). A total of 92% of patients had DVT in the calf veins. There was no difference between surgical and nonsurgical patients with regard to the location of the thrombi. Fifteen postoperative DVTs occurred despite prophylaxis with low-molecular-weight heparin. A considerable number of patients (14) had no prophylaxis.

The authors conclude that age over 40 and female gender are significant risk factors and that in only 8% of cases was there no identifiable associated risk factor. They further conclude that they saw no difference in the distribution extent of postoperative thrombosis in relation to prophylaxis. On the other hand, they had more high-risk patients in the prophylaxis group. The authors state that there are other studies which find that in symptomatic patients, it is more common to find proximal thrombi, contradicting the present study outcome. The final conclusion, therefore, is that a careful study of calf veins is important in symptomatic patients.

COMMENTARY

This study suffers the common problem of being retrospective and the reader has little insight into what patients were referred for workup. It seems patients were referred from both outside the hospital and from medical departments at the hospital as well as other surgical disciplines. If this means that the surgical unit was the only place caring for patients with suspected DVT, selection might not be of any great importance. However, if this is a selected group of patients, interpretation has to be viewed with great care.

Further, there is no information on what is meant by symptomatic and what kind of criteria were used to refer a patient for venography. On the other hand, of 187 patients, 76 had a positive venogram (40%) which is a reasonable figure in a non-selected patient population.

The authors comment that the incidence of DVT despite low-molecular-weight heparin prophylaxis was high. However, there is no information on how the prophylaxis was accomplished. One might comment that 11 patients had immobilization for more than five days.

This study contradicts the study from Padua finding that a majority of patients had a proximal DVT. It is impossible to make any more relevant comparison as the selection criteria are not known. The conclusions from these two studies are also contradictory with present study claiming the importance of evaluating calf veins. The implication could be that ultrasonography, not examining the crural veins, might miss the DVT.

In this kind of study the information given is almost impossible to interpret without knowing the selection criteria. Clearly, prospective studies following a strict protocol are required. ivdfnor1

REFERENCE

1. Cogo A, Lensing AW, Prandoni P, Hirsh J. Distribution of thrombosis in patients with symptomatic deep vein thrombosis: Implications for simplifying the diagnostic process with compression ultrasound. Arch Intern Med 1993; 153:2777-80.

INFLUENCE OF A SPECIALIZED LEG ULCER SERVICE AND VENOUS SURGERY ON THE OUTCOME OF VENOUS LEG ULCERS
Ghauri ASK, Nyamekye I, Grabs AJ, Farndon JR, Whyman MR, Poskitt KR
Eur J Vasc Endovasc Surg 1998; 16:238-44

ABSTRACT AND COMMENTARY BY:
Prof. dr. hab. med. Zygmunt Mackiewicz
Bydgoszcz, Poland

This study assesses the influence of noninvasive vascular assessment and superficial venous surgery on the outcome of chronic leg ulcers within a community service. All patients who were being treated for leg ulcers in the community by district or practice nurses during a three-month period were identified from prospectively completed computerized patient database and general practitioner file records. A sample of 200 patients was selected. Exclusion criteria included duration of leg ulceration less than four weeks, arterial or malignant etiology, and ulcers outside the gaiter region. Five community-based leg ulcer clinics were established to which patients were referred. Each limb was initially assessed for arterial disease using hand-held Doppler to measure ankle brachial index. Venous dysfunction was assessed using color venous duplex ultrasonography. Venous patency and reflux were assessed in the common femoral, superficial femoral, popliteal, saphenofemoral junction, greater and lesser saphenous, and perforator segments.

Patients were seen weekly in community clinics and four-layer, graduated-compression bandaging was applied. Patients with superficial venous incompetence in the absence of deep venous incompetence on duplex imaging were offered corrective superficial venous surgery to the affected limb. Ulcers with horizontal length more than 3 cm were pinch grafted in the community clinics. Healed limbs were treated with grade 2 below-knee compression stockings. Healing rates at 12 and 24 weeks were calculated. All statistical analyses were performed on a PC.

Healing and recurrence rates were compared between the ulcerated limbs (n = 149) in a random sample of 200 patients treated in the community clinics and consecutive limbs (n = 200) from 180 patients treated in specialized clinics.

After the five clinics were established, healing rates increased from 12% to 53% at 12 weeks and from 29% to 68% at 24 weeks (p = 0.01). Recurrence rates decreased from 43% to 21% at six months and from 54% to 23% at 12 months (p = 0.01). Superficial venous surgery reduced recurrence to 9% at one year.

The authors conclude that the outcome of leg ulcers is improved by a vascular-led community service, that compression bandaging should be applied to limbs with an ankle brachial index less than 0.85, and that routine surgical correction should be done in cases with reflux limited to the superficial venous system as this may further reduce the chance of recurrence.

COMMENTARY

In my opinion, these investigations confirm that suitable bandaging of legs with chronic venous insufficiency reduces the probability of ulceration. Compression therapy performed by well-educated physicians or nurses can reduce ulcer recurrence rate during 12 and 24 months of followup. It is very important that a correct diagnosis be made by Doppler and duplex examinations. One can assess the arterial flow in the limb (ABI) and the other can also assess the graduation of reflux in the deep and superficial venous systems.

The results suggest that improvement in leg ulcer outcome may be achieved by appropriate treatment in specialized vascular-led community clinics. While this kind of treatment is not possible in every country, I believe that stressing the importance of compression therapy in improving ulcer healing to medical students and nurses is the best alternative to improve ulcer healing.

The important conclusion of this investigation is the role of surgery to reduce recurrence of healed ulcers to 9% after one year.

I agree with the authors that color venous duplex provides the most accurate noninvasive method of patient selection and that surgical correction of superficial venous diseases is most important to decrease recurrence.

It is known that even after well-done compression therapy and surgery to the superficial veins, there will still be a number of patients with nonhealed leg ulcers. In my opinion, there are not a great number of patients with indications for special hemodynamic examinations such as venous refilling time by plethysmography, venous reflux index by air plethysmography, or descending phlebography using Kistner's classification in the deep venous system. These will lead to a meticulous selection of patients for venous reconstructive surgery, especially for venous valve reconstruction which can also reduce the number of non-healed leg ulcers. In my experience, however, that kind of treatment is applied in a very selective group of patients. ivdfmac1