THREE YEARS' EXPERIENCE WITH POLIDOCANOL FOAM IN TREATMENT OF RETICULAR VARICES AND VARICOSITIES
Henriet JP
PhlÈbologie 1999; 52:277-82

ABSTRACT AND COMMENTARY BY:
Docteur Robert Stemmer
Illkirch, France

Publications concerning therapy can generally be divided into two categories. One describes techniques and another usually publishes results of techniques. Sometimes both become combined into a single paper. The first description of a technique may be dangerous because it may only be an idea which has not been tested and about which there is no experience. Therefore, the greatest caution should be advised in considering a new technique.

The field of phlebology has had no new sclerosants in recent time. The main reason is that they have limited use and their cost needs to be kept relatively low. This impedes research and even affects registration of older sclerosants. This explains why very good but old sclerosants are cancelled from distribution.

The observations made earlier about therapeutic techniques applies to sclerotherapy of varicose veins. For example, sclerotherapy under duplex scanning control at the saphenofemoral junction, as described years ago, has gone through the preliminary descriptive phase into the publication-of-results era. Duplex-controlled sclerotherapy requires great experience in sclerotherapy and a duplex scanner. These two requisites are not always in the same place at the same time. Instruction in performing the technique is not promoted by universities or policlinics. When angiology is recognized as a specialty by health authorities, instructions will come easier.

J. P. Henriet and some others have published an important improvement in sclerotherapy of telangiectasias and reticular varicosities. They use a simple technical trick which is accessible to every phlebologist and is based on Henriet's great experience. The Henriet technique improves considerably the foam method described in 1944 by Orbach which he called "air block." Orbach produced foam by shaking sodium tetradecyl sulfate; however, the foam produced had bubbles that were between 3 and 7 mm in diameter. Monfreux published a foam method in 1995. His original idea was adopted and amended by Henriet.

Henriet uses glass 3 ml syringes, into which 0.3 to 0.4 ml of polidocanol is made up as a 0.5% solution and then diluted with 0.1 to 0.2 ml of physiologic serum. A dilution will depend upon the caliber of the treated varicose veins. The opening of the syringe is blocked with a sterile plug and slow traction on the plunger causes small air bubbles to appear in the liquid. These penetrate the solution between the plunger and the body of the syringe. The force of the traction determines the diameter of the bubbles, and slow traction is recommended. When the bubbles with a diameter between 0.6 and 1.3 mm fill the 3 ml syringe, traction is stopped. The sterile plug is then replaced by a 26- or 30-gauge needle and the sclerosing injections may proceed.

The foam, as it is injected, prevents secondary back-bleeding because this impedes blood reflux. The foam is in contact for a long time and therefore the concentration of the sclerosant can be reduced.

Between November 1995 and September 1998, 10,263 patients were treated with approximately 70,000 injections. Five to ten injections were given in a single session. The results of the method were not precisely quantified but were subjectively compared with the previous method which involved sclerotherapy without foam. The authors state that the advantage of this method is the mild concentration of sclerosant which is 0.3 to 0.4% for reticular varicosities and 0.1 to 0.2% for telangiectasias. Less than 0.5 ml is given per injection site, and this allows a smooth injection with perfect control of the intraluminal portion of the needle. There is a diminution of the risk of sclerotherapy because of the dilution of the dosage and this, in turn, decreases cost. It has been found that compression after such an injection technique does not provide an additional advantage.

This foam technique can only be done with tensioactive sclerosants such as sodium tetradecyl sulfate or polidocanol. Furthermore, it is difficult to achieve a fine foam with the usual plastic syringes. However, this would vary depending on the source of the syringes and, therefore, interested physicians can check their own resources.

After the foam is prepared in the syringe, it lasts for approximately one minute. Henriet himself only uses 3 ml as the maximum volume which would be injected in any one session.

Complications of this method are not frequent (2%), less than the classic method of sclerotherapy without foam. The amount of air injected is less than 3 ml, far below the harmful limit, thought to be about 500 ml of air in an adult patient. It is felt that this foam block method yields less complications than the traditional method with at least equal results. This technique can be recommended for anyone who does sclerotherapy of telangiectasias without the use of foam. vdste292




QUALITY ASSURANCE IN PHLEBOGRAPHY OF THE EXTREMITIES (Qualitaetssicherung bei der Extremita et en Phlebographie)
 Weber J.
VASA 1999; 28:216-22

ABSTRACT AND COMMENTARY BY:
Reinhard Fischer, M.D.
Wattwil, Switzerland

Phlebography was formerly the golden standard in venous diagnosis but it sees itself now in competition with a number of functional tests and minimally invasive and noninvasive imaging techniques. The invasiveness of phlebography has been reduced enormously in recent time since nonionic low-osmolarity contrast media was introduced. Only a few relative contraindications to phlebography remain. These include pregnancy, severe renal failure, hyperthyroidism, and allergy to iodinated contrast media.

One finds in this paper a detailed description of the sites and techniques of venous puncture as well as the technical conduct of the entire examination. Safety precautions are clearly discussed. The different contrast media are listed, including information on the indication for each and the concentration and volume to be used. Weber stresses that the type and extent of phlebography needs to be chosen according to a specific phlebologic indication and the facilities of the examining institution. He also describes need for adequate documentation and supplies its description.

Participants of an interdisciplinary group formulated different indications for phlebography and for duplex ultrasound examination as follows:

  1. Spider bursts, telangiectasias, small side branches: If necessary duplex, very rarely phlebography

  2. Greater and lesser saphenous varices: Duplex in surgical cases, if necessary phlebography

  3. Postoperative recurrence: Duplex and phlebography

  4. Acute thrombosis, pelvis: Duplex and phlebography, if necessary DSA

  5. Acute thrombosis, thigh: Compression, duplex and phlebography

  6. Acute thrombosis, leg: Duplex and phlebography

  7. Postthrombotic syndrome, morphology: Phlebography

  8. Postthrombotic syndrome, function: Phlebodynamometry and duplex, rarely phlebography
COMMENTARY

It was under the leadership of J. Weber that a group of prominent angiologists, phlebologists, radiologists, and vascular surgeons set quality standards for phlebography. At the same time as described in this article, the characteristics of generally accepted guidelines on phlebography were stated. Weber is one of the leading phlebologic radiologists in Europe. He began modern phlebography when working with the late vascular surgeon, Robert May. Since then, he has perfected his techniques and has published a vast literature on phlebography.

In Europe, there is a consistent move away from phlebography towards duplex ultrasonography. Our group has also moved in this direction. Therefore, we have made some observations: Phlebography is difficult to interpret and it is often difficult to find someone qualified to do this. The less phlebography is done, the more this holds true. We refer patients for phlebography when something relevant cannot be assessed by duplex ultrasonography.

For varicose vein surgery, we see best results with the following protocol. A primary consultation includes the history, inspection, and the necessary additional tests, including duplex. This takes about one hour. Preoperative duplex-assisted marking is done in the presence of a member of the surgical team. Some surgeons prefer to have phlebography available during surgery. Whenever documentation is important, there is nothing better than phlebography, particularly in legal cases. vdfis319

SUGGESTED READING

1. Weber J, May R. Funktionelle Phlebologie. In: Phlebographie, Funktiontests, Interventionelle Radiologie. Thieme, Stuttgart, New York, 1990.

2. Weber J. Phlebologie: Indikations-stellung, Untsuchung-stechniken, Qualitatssicherung. In: Marshall M, Breu FK (eds). Handbuch der Angiologie. Ecomed, Landsberg, 1999.




THE EFFECT OF COMPRESSION ON VENOUS HEMODYNAMICS ASSESSED BY QUANTITATIVE PHOTOPLETHYSMOGRAPHY
Fronek A, Goldman M, Fronek K.
Phlebology 1998; 13:98-101

ABSTRACT AND COMMENTARY BY:
Stephen G. Lalka, MD
Professor of Surgery
Division of Vascular Surgery
Indiana University Medical Center
Indianapolis, Indiana

The authors examined the effect of compression stockings at the level of the ankle using computer-controlled quantitative photoplethysmography (PPG). Three groups of subjects were studied: Normal controls (8), patients with telangiectatic veins (10), and patients with varicose veins (11). The PPG probe was positioned 8 cm above the medial malleolus. Parameters measured included exercise displacement volume (EDV), the amount of blood displaced by the legs after eight dorsiflexions, tilt displacement volume (TDV), the amount of blood displaced passively by raising the limbs above heart level, and the recovery time (RT) to limb refilling. The calculated parameters, EDV/TDV, represented the efficiency of the venomuscular pump. All parameters were measured before and after application of a grade 1 (20 to 30 mmHg) compression stocking applied to the tested limb over the PPG transducer without cutting a hole in the stocking.

There was a statistically significant increase in EDV (% optical reflectance) with compression only in the varicose vein group: 4.8% (SE 0.64) to 7.5% (SE 0.83) (p < 0.05). There was no significant change with compression in the TDV or RT in any group. Venomuscular efficiency, EDV/TDV, increased significantly (p < 0.01) in all three groups.

The authors conclude that venomuscular efficiency, EDV/TDV, was the most sensitive and practical parameter demonstrating the effect of external compression on venous hemodynamics as documented by quantitative photoplethysmography.

COMMENTARY

This article provides useful information on three aspects of venous disease: Parameters that can be measured to document the state of venous hemodynamics, methods of assessing venous hemodynamics, and the efficacy of external compression stockings.

Venous refill or recovery time (RT) has been the parameter usually measured by PPG. The RT obtained with PPG tracings (while correlating with the RT measured by direct venous pressure monitoring) does not correlate with ambulatory venous pressure (AVP) and therefore lacks quantitative value in determining the severity of venous reflux. The PPG RT is susceptible to variation in transducer position and type of exercise. There is also substantial variability in repeated RTs in the same individual. This inadequacy of the RT parameter was confirmed in this study when there was no change in any group with compression.

The authors introduce the exercise displacement volume (EDV), the passive tilt displacement volume (TDV), and most importantly, their calculated ratio (EDV/TDV) as a measure of the efficiency of the venomuscular pump and its effect at the ankle level (the prime target of potential trophic sequelae of chronic venous insufficiency). The EDV/TDV ratio was demonstrated to be a parameter that could quantify the efficacy of external compression stockings in improving venous hemodynamics at the ankle. By obtaining the EDV and the TDV (using a built-in program for timing the series of measurements in each limb), computer-controlled output D-PPG was shown to be a reliable, reproducible, quantitative method of assessing venous hemodynamics, both for the diagnosis of CVI and for documentation of the efficacy of therapeutic interventions such as external compression.

We should look forward to further studies using EDV/TDV as measured by D-PPG to document both the severity of CVI and the effect of surgical intervention on venous hemodynamics at the ankle. A study evaluating the correlation between EDV/TDV and AVP would be particularly interesting. vdlal319




VEINS OF THE INGUINAL LYMPH NODES (Veines Lympho-Ganglionnaires Inguinales)
 Lemasle P, Uhl JF, Lefebre-Vilardebo M, et al.
PhlÈbologie 1999; 52: 263-69

ABSTRACT AND COMMENTARY BY:
Herrn Prof. Dr. med. H.-J Leu
Novaggio, Switzerland

The authors describe a small-caliber, tortuous venous network located within the inguinal lymphoganglionic lamina situated between the long saphenous vein and the anterolateral saphenous vein tributary running in a transganglionic direction. Anatomically, this network is always present and can be recognized by color echo-Doppler. In 6% of the cases investigated, it was incompetent and responsible for the development of primary truncular varicose veins of the long saphenous system without ostial incompetence of the latter vein. In the literature, this network has been described as a neogenesis causing postoperative relapse. In view of the anatomic preexistence of this network, the authors refute the term neogenesis and rather consider it to be a revascularization due to the enlargement of already existing veins.

COMMENTARY

The occurrence of large dilated veins perforating inguinal lymph nodes was first described in 1990 and then later in 1997.1,2 It was, perhaps erroneously, considered an angiodysplasia. Since one of the first five cases and also the case described in 1997 occurred in relapsing varicose veins after surgical ligation of the saphenofemoral junction, the possibility for collateral circulation was mentioned. Considering the interesting observations of these French authors, several possible explanations exist. These include:

  1. A malformation comprising singular branches of a preexisting venous network.

  2. Collateral circulation developing from the enlargement of preexisting veins following an earlier ligation of the saphenofemoral junction.

  3. A primary varicosis of one or several branches of a preexisting venous network, independent of a simultaneously existing incompetence of the saphenofemoral junction. vdleu319

REFERENCES

1. Virchow's Arch Pathol Anat 1990; 417:185-86.

2. Kohler A, Dirsch O, Brunner U. VASA 1997; 26:52-54.




GUIDELINES OF VENOUS DIAGNOSIS BY STRAIN-GAUGE VENOUS OCCLUSION PLETHYSMOGRAPHY
 Gerlach H, Partsch H, Rabe E, Gallenkemper G, J¸nger M
Phlebology 1999; 28:68-69

ABSTRACT AND COMMENTARY BY:
Manuela Birrer, MD
Prof. F. Mahler
Berne, Switzerland

This distinguished group of physicians, all of whom are interested in venous pathophysiology, have set down guidelines for the use of strain-gauge plethysmography in diagnosis of deep venous thrombosis (DVT). Strain-gauge venous occlusion plethysmography does provide a noninvasive method of measuring blood volume changes in the extremities indirectly. As volume changes accompany deep venous thrombosis, this technique might be applied in screening limbs for this diagnosis.

The standard protocol should include the determination of arterial resting flow and the limb should be elevated 45 degrees if the straight-leg technique is used or 30 degrees with the knee flexed and the calf in a horizontal position. The maximum venous outflow should be determined after three minutes of thigh cuff occlusion. The cuff should be 12 cm in width and should be inflated slowly to 60 to 80 mmHg. After three minutes, the tourniquet is released suddenly. Venous capacity and maximum venous outflow per second should be determined. Dynamic muscle contraction will allow examination of valvular function.

Results of venous occlusion strain-gauge plethysmography may be distorted by edema, induration, or severe arterial occlusive disease. Other technical factors such as insufficient width of the cuff, tight application of the mercury strain gauge, the room temperature, or slow cuff release may be present.

Venous occlusion plethysmography does permit a quantitative evaluation of subfascial venous outflow. This allows detection of venous occlusion proximal to calf veins. Normal values of venous capacity are 2.51 to 5.0 mm per 100 ml of tissue, and 35 to 100 ml per 100 ml should be the value for maximum venous outflow. This, of course, is dependent upon venous capacity. When proximal DVT is present, these values are decreased and, in the presence of marked varicose veins, they are increased. Deep venous damage occurring from previous DVT may alter venous capacity in a positive or negative direction but maximum venous outflow is usually decreased.

COMMENTARY

Although this distinguished group of colleagues has provided guidelines for deep venous thrombosis detection through this easily performed noninvasive test, in fact, its sensitivity is around 90%. This test is rarely used in our laboratories, mainly because of the easily availability of compression ultrasonography. Dynamic plethysmography might allow evaluation of valvular function with regard to therapeutic interventions or exclusion of venous claudication in a differential diagnosis. vdmah214




ENDOTHELIAL ACTIVATION IN PATIENTS WITH CHRONIC VENOUS DISEASE
Saharay M, Shields DA, Georgiannos SN, Porter JB, Scurr JH, Coleridge Smith PD.
Eur J Vasc Endovasc Surg 1998; 15:342-49

ABSTRACT AND COMMENTARY BY:
Prof. Claudio Allegra
Rome, Italy

The authors investigated endothelial activity as an index of leukocyte/endothelial adhesion in normal controls and in patients with chronic venous insufficiency subjected to short-term venous hypertension. They measured the plasma levels of ELAM-1, ICAM-1, VCAM-1 and von Willebrand factor (vWf) before and after short-term venous hypertension.

Patients with venous disease were subdivided into two groups: Group 1 (LDS), patients presenting with lipodermatosclerosis or hemosiderotic skin changes and group 2 (VV), patients presenting without skin changes. Patients with concomitant disease or on medication known to alter white cell activity were excluded from the study. Complete blood count on samples collected from the dorsum of the foot showed a rise in hemoglobin, red cell count, white cell count, and hematocrit on standing.

Leukocyte trapping was confirmed by calculating the white/red cell ratio. In both the controls and the patients, the ratio fell significantly in response to venous hypertension, confirming the sequestration of leukocytes. No significant difference in leukocyte sequestration was noted between group 1 and group 2. Basal levels of all three adhesion molecules (ELAM-1, ICAM-1, VCAM-1) were significantly higher in patients compared to controls. In group 1, basal plasma VCAM-1 and its magnitude of rise in response to experimental venous hypertension was significantly higher compared to group 2. There was no difference in the magnitude of rise in ICAM-1 and ELAM-1 between the two groups. However, patients with lipodermatosclerosis had significantly higher basal plasma vWf compared to patients without skin changes. There was no significant change noted in either group in response to experimental venous hypertension.

COMMENTARY

Coleridge Smith, Scurr and Dormandy proposed the white cell trapping hypothesis after investigating the causes of venous ulceration through videomicroscopy and leukocyte count in blood samples collected from the foot after experimental venous hypertension in patients with chronic venous insufficiency and in healthy controls (Br Med J 1988; 296:1726). They suggested that raised venous pressure led to decreased flow which in turn caused leukocyte margination, activation, adhesion, and extravascular migration. The release of proteolytic enzymes and free radicals from activated leukocytes resulted in tissue damage. This hypothesis was supported by histological evidence of white cell infiltration of the tissues in skin biopsies from patients with chronic venous insufficiency.

A complex interaction of physical, biological, and biochemical factors control and modulate leukocyte/endothelial cell adhesion and leukocyte migration into the tissues. Many adhesion molecules are expressed by leukocytes and endothelial cells in response to physiological and pathological stimuli. Vascular endothelial cells express the adhesion molecules ELAM-1 (endothelial leukocyte adhesion molecule-1), ICAM-1 (intercellular adhesion molecule-1), and VCAM-1 (vascular cell adhesion molecule-1). These are all cell surface glycoproteins generally expressed in response to cytokine activation.

Increased levels of adhesion molecules and vWf suggest that endothelial activation is a feature of chronic venous insufficiency. Such increase is presumably due to endothelial damage in the skin, is supported by histological evidence, and is presumably due to free radical and proteolytic enzyme release from activated leukocytes. Perivascular macrophage infiltration in skin capillaries shown by histological studies may be favored by the increased expression of VCAM-1 by the endothelium. Leukocyte sequestration and activation, together with endothelial activation in chronic venous insufficiency, are features of the pathophysiology of skin alterations in CVI. These participate in the failure of the microcirculation which finally results in skin ulceration.

The authors investigated only a particular aspect of the complex physical/biochemical mechanisms involved in microcirculatory impairment. Can leukocyte trapping and consequent activation represent an unique phenomenon in CVI or is it a pathophysiological phenomenon linked to any inflammatory event? Is it not true that leukocytes are collected in any area where inflammation occurs? Is it true that reperfusion damage is strictly dependent on the possibility of leukocyte activation reversibility? If so, the present research assumes a role of elegant assessment of a nonspecific phenomenon. ivdfall2

Suggested Reading

1. Haskard DO, Nourshargh S, Von Uexkull CV et al. Int J Microcirculation Clin Exp 1992; 11(Suppl 1):114-16. Kluwer Academic Publishers.




EFFECTIVE TREATMENT OF LYMPHEDEMA OF THE EXTREMITIES
Ko SCK, Lerner R, Klose G, Cosimi AB
Arch Surg 1998; 133:452-58

ABSTRACT AND COMMENTARY BY:
Prof. Claudio Allegra
Rome, Italy

This is a prospective study of 299 consecutive patients affected with lymphedema of the upper extremity (2% primary, 98% secondary) or lower extremity (61.3% primary, 38.7% secondary) treated with complex decongestive physiotherapy (CDP). CDP is a two-phase noninvasive therapeutic regimen. Phase 1 includes: a) Manual lymphatic drainage, a massage technique that stimulates lymph vessels to contract more frequently, channeling lymph and fluid toward adjacent functioning lymphatics, b) multilayered non-elastic compression bandaging done immediately after manual lymphatic drainage, c) remedial exercises with the muscles and joints functioning within a closed space that may help increase lymph flow in all available lymph channels and collateral pathways, and d) meticulous skin and nail care including eradication of any infection with antibiotics. Phase 2 (maintenance phase) consists of continued meticulous skin and nail care, surgical support garments worn during the day and low-stretch bandages worn overnight, and a short sequence of specific exercises repeated each morning while still bandaged.

The average duration of phase 1 was 15.7 days. Average limb volume in milliliters was calculated prior to treatment, at the end of phase 1, and at six-and 12-month followup visits during phase 2 in order to assess lymphedema reduction as percent volume reduction. Lymphedema reduction averaged 59.1% after upper extremity CDP and 67.6% after lower extremity treatment. After an average followup of nine months, the improvement was maintained in compliant patients (86%) at 90% of the initial reduction for upper and lower extremities. Noncompliant patients lost some of their initial reduction (33%). The incidence of infection decreased from 1.10 infections per patient per year to 0.65 infections per patient per year after a complete course of CDP.

COMMENTARY

Surprisingly, no significant difference was noted in response to treatment in the upper and lower extremities. It is commonly agreed that fibrosis caused by operation and radiation therapy for breast cancer results in more severe lymphedema than the variable congenital abnormalities occurring in the lower extremities. Perhaps the type of node dissection, the number of nodes harvested, or even obesity influences the occurrence and course of upper extremity lymphedema.

The results of CDP in secondary lymphedema may suggest the presence of large lymphatic reserves that may open with the manual decompressive technique. In addition, once the initial response is achieved, the maintenance phase of CDP is independent from those physiological constraints associated with fibrosis. A partial reversibility in mild cases of secondary lymphedema associated with axillary node dissection has to be considered. This implies that early treatment should be initiated promptly. Use of pneumatic pumps is uniformly disappointing in the treatment of lymphedema. Therefore, these should not be recommended as effective therapy.

Most of the patients in this study had tried all other modalities of therapy. Some had even attempted surgical intervention with little or no success. Consequently, they willingly accepted CDP as their last hope and observed meticulously the detailed lifestyle modifications.

It would be interesting to see a randomized study comparing CDP to decongestive physiotherapy without manual lymphatic drainage in order to clarify the relative contributions of the different components of treatment. ivdfall1

Suggested Reading

1. Boris M, et al. Persistence of lymphedema reduction after noninvasive complex lymphedema therapy. Oncology 1997; 11:99-109.

2. Campisi C, et al. Derivative lymphatic microsurgery: Indications, techniques and results. Microsurgery 1995; 16:463-68.

3. Filippetti M, et al. Modern therapeutic approaches to post mastectomy brachial lymphedema. Microsurgery 1994; 15:604-10.

4. Foeldi E, et al. Conservative treatment of lymphedema of the limbs. Angiology 1985; 36:171-80.




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


Psychosocial Stress and Quality of Life with Lymphedema
Bross F, F–ldi E, Vanscheidt W, Augustin M
Phlebologie 1999; 28:70-74

This article gives a valuable overview on the psychosocial aspects of lymphedema based on the literature but backed up by the enormous experience of the respected F–ldi Klinik.


Underuse of Venous Thromboembolism Prophylaxis for General Surgery Patients: Physician Practices in the Community Hospital Setting
Bratzler DW, Raskob GE, Murray CK, et al.
Arch Intern Med 1998; 158:1909-12

Despite widely disseminated evidence-based recommendations, venous thromboembolism prophylaxis is underused.


Contact Allergens in Patients with Leg Ulcers
Katsarou-Katsari A, Armenaka M, Katsenis K, et al.
J Eur Acad Dermatol Venereol 1998; 11:9-12

Changing trends in contact allergens over 20 years may be explained by changes in the components of topical agents used in treatment of venous leg ulcers.


Role of Lasers and Light Sources in the Treatment of Leg Veins
Dover JS, Sadick NS, Goldman MP
Dermatol Surg 1999; 25:328-36

In this editorial, the author's state, "Because of the relatively modest results demonstrated with lasers and light sources and the high rate of success and relatively low cost of ambulatory phlebectomy, compression sclerotherapy, and superficial sclerotherapy, we generally recommend using lasers and light sources only for vessels that remain after these treatment approaches."


Acute Massive Pulmonary Embolism Following High Ligation Combined with Compression Sclerotherapy for Varicose Veins
Yamaki T, Nozaki M, Sasaki K
Dermatol Surg 1999; 25:321-25

While the incidence of this dangerous complication is unknown, the fact is deep venous thrombosis does follow compression sclerotherapy and, in a commentary on the case report, Mitchel P. Goldman, MD stated, "The lesson is that one should not perform sclerotherapy at the same time that one is either performing an operation...or any form of surgical procedure that prevents the patient from being fully ambulatory."


Subfascial Perforator Vein Ablation: Comparison of Open Versus Endoscopic Techniques
Sato DT, Goff CD, Gregory RT et al.
J Endovasc Surg 1999; 6:147-54

As expected, early outcomes are the same in the two groups which compared open operation to subfascial endoscopic perforator surgery and, as predicted, fewer complications occurred in the SEPS group.


Percutaneous Iliocaval Thrombectomy with the Amplatz Device: Preliminary Results
Gandini R, Maspes F, Sodani G et al.
Eur Radiol 1999; 9:951-58

Very little surgical thrombectomy is being practiced in the United States. The new thrombectomy devices which homogenize and otherwise attempt to obtain mechanical clot dissolution may replace the surgical attempts in patients with excessive thrombus burden.