JANUARY 2000 ANNOUNCEMENT

 Beginning with this January 2000 issue, the Venous Digest is being sent to all United States members of the American Venous Forum and the American College of Phlebology at no charge. The objective of these organizations is the same as that of the Venous Digest and, in working together, we can definitely improve the care of patients with venous disease.

The American Venous Forum brings together annually well-recognized authorities on all aspects of venous disease: Diagnosis, pathophysiology, and treatment. There, most recent research is presented and discussed.

The purpose of the American College of Phlebology is the advancement of the art and science of phlebology. It provides a forum for physicians interested in venous diseases. It seeks to improve understanding of the diagnosis and treatment of venous disorders by physicians and seeks to improve the delivery of care of these conditions to the public.




A PROSPECTIVE, RANDOMIZED TRIAL OF PIN VERSUS CONVENTIONAL STRIPPING IN VARICOSE VEIN SURGERY
 Durkin MT, Turton EPL, Scott DJA, Berridge DC
Ann R Coll Surg Engl 1999; 81:171-74

COMMENTARY BY:
Prof. Dr. Mehmet Kurtoglu
Trauma and Surgical Emergency Department
University of Istanbul Medical School
Istanbul, Turkey

As stated in the title, this is a prospective, randomized study of 80 patients with varicose veins secondary to saphenofemoral junction and long saphenous vein (LSV) insufficiency. The patients were randomized by computer to conventional stripping (37) or PIN stripping (43). The surgeons were informed of the randomization immediately prior to stripping. All other technical details were the same in both groups. In this trial, only one LSV was stripped to below knee and there were additional stab wounds for the varicosities. Both groups were compared according to duration of surgery, completeness of stripping, size of the exit site, and the area of bruising as traced on transparent acetate. The study results revealed no significant difference between the two techniques in terms of time, completeness of stripping, or area of bruising. Use of the PIN stripper did result in a smaller exit wound than the conventional stripper and this was statistically significant (p < 0.001).

COMMENTARY

In the PIN stripping operation, the proximal cut end of the LSV in the groin is inverted by the PIN device enabling removal of the inverted vein through a small distal incision. The small olive head of the conventional stripper leaves a 2 mm larger scar below the knee. Since varicose vein surgery is often done for cosmetic reasons, the reduction in size of the scar is significant. However, I am not persuaded to change techniques simply because of a 2 mm reduction in one incisional scar. The groin and other stab incisions remained the same with both procedures.

Although it was not found to be statistically significant, the groin infection rate was about three times greater in PIN stripping. This must have a negative effect on patient comfort. Another undesirable complication is calf paresthesias. The PIN device did not provide any advantage in protection from risk of nerve injury. The authors did support the usefulness of stripping the LSV to the ankle and agree that this might cause more nerve damage. Although I had hoped that the PIN device technique would have less risk of nerve injury, this was not confirmed. I personally believe that total stripping is more effective in cases of total LSV and perforator vein insufficiency. I expect that inversion stripping may reduce the risk of nerve injury in cases of LSV stripping to the ankle.

I believe it unfair to compare the cost of the disposable conventional stripper with the cost of the reusable PIN stripper as one can reuse the re-sterilized conventional stripper which is more cost effective.

In summary, the PIN stripping technique may be useful but I agree with the authors that the stripping device chosen must remain the surgeon's personal choice. The inversion technique could be less traumatic for LSV stripping to the ankle, and this may be a worthwhile study in the future. ivdfkur2




PREOPERATIVE DIGITAL PHOTOPLETHYSMOGRAPHY PREDICTS IMPROVEMENT IN VENOUS FUNCTION AFTER SUPERFICIAL VENOUS SURGERY FOR CHRONICALLY ULCERATED LIMBS
 Sullivan JG, Ghauri ASK, Whyman MR, Poskitt KR.
Phlebology 1998; 13:142-47

ABSTRACT AND COMMENTARY BY:
Prof. dr. hab. med. Zygmunt Mackiewicz
Professor of Surgery
Head, Department of General & Vascular Surgery
Bydgoszcz, Poland

The last 20 years of experience in treatment of chronically ulcerated limbs has shown the importance of compression therapy and positive effect of community ulcer clinics in the healing of chronic venous insufficiency (CVI). Unfortunately, the recurrence rate after conservative treatment is still high.

The authors suggest that approximately 50% of limbs with chronic venous ulcers have dysfunction of the superficial venous system. This can be treated with surgical methods. They propose examination to predict the influence of surgery on calf pump function. They advocate color venous duplex which provides information on venous reflux. With digital photoplethysmography (d-PPG), they measure venous refill time (VRT) and pump power (PP) measured with or without the tourniquet and before and after surgery.

A total of 27 patients with 30 ulcerated limbs were entered into this study. The presence of superficial reflux for each limb was demonstrated by color venous duplex. VRT increased preoperatively from a median of 10 seconds to 26 seconds with the tourniquet above and below the knee. After superficial venous surgery (stripping) the mean value of VRT was 19 seconds. Median pump power increased from 2.3% preoperatively to 3.0% with the tourniquet above the knee. Values of PP with the tourniquet below the knee and after surgery were 2.9 and 4.4, respectively. The increase in VRT with an above-knee tourniquet preoperatively correlated with the increase of VRT after surgery.

A total of 24 of 30 ulcerated limbs (80%) had healed less than 12 weeks after surgery. Limbs with delayed ulcer healing had less improvement in postoperative VRT than those with more rapid ulcer healing. This difference was not accurately predicted by the preoperative tourniquet test.

The authors conclude that superficial venous surgery improves venous function as measured by d-PPG in chronically ulcerated limbs. Preoperative assessment with d-PPG and above-knee tourniquet predicts functional improvement after surgery. This study presents an important assessment of two noninvasive examinations (venous color duplex and photoplethysmography) as indicators for superficial venous surgery in patients with chronic leg ulcers.

COMMENTARY

Introduction of the venous duplex Doppler examination as applied to chronic venous insufficiency has given us the possibility to make an accurate diagnosis and then to decide on indications for surgery versus conservative care. There are an increasing number of reports in recent years which have stressed the importance of superficial venous reflux in the pathologic process of venous hypertension and limb ulceration. The question remains how to treat chronic venous insufficiency, whether to apply compression therapy alone or combine this with surgery.

The present investigations show very clearly that failures of compression therapy should be operated upon. This study suggests that surgery should be performed in situations when the color duplex examination shows reflux at the saphenofemoral junction and the tourniquet test with D-PPG indicates improvement of the VRT. However, this study also shows that there is no regular correlation between the preoperative testing and ulcer healing after surgical intervention. In my opinion, the preoperative investigation should uncover deep venous reflux in the femoral and popliteal veins. Such reflux can be a cause of failure of superficial venous surgery and a measurement of this reflux using the Psathakis index may help to predict results of surgical intervention. Venous valve reconstructive surgery may be the final choice for patient limbs that are resistant to other forms of therapy. ivdfmac3




PRIMARY SUPERFICIAL VEIN REFLUX WITH COMPETENT SAPHENOUS TRUNK
 Labropoulos N, Kang SS, Mansour MA, Giannoukas AD, Buckman J, Baker WH
Eur J Vasc Endovasc Surg 1999; 18:201-06

NEW INSIGHTS INTO PERFORATOR VEIN INCOMPETENCE
Labropoulos N, Mansour MA, Kang SS, Gloviczki P, Baker WH
Eur J Vasc Endovasc Surg 1999; 18:228-34

ABSTRACT AND COMMENTARY BY:
John J. Bergan, MD, FACS
Professor of Surgery, University of California, San Diego
Clinical Professor of Surgery, USUHS, Bethesda, Maryland

The role of noninvasive testing prior to surgery for varicose veins and superficial reflux is unsettled. These two publications from the Division of Vascular Surgery at Loyola University Medical Center near Chicago provide persuasive documentation for the fact that duplex scanning is a valuable adjunct prior to superficial vein surgery and that use of duplex scanning has revealed valuable new information about pathophysiology of perforating veins.

ABSTRACT

In the first presentation, the study was designed to identify the distribution and extent of reflux in nonsaphenous veins and to relate this to the findings of severe chronic venous insufficiency. Eighty-four (84) limbs in 62 patients with symptoms and signs of chronic venous disease were examined with color-flow duplex imaging. This followed examination in the clinic with hand-held continuous-wave Doppler instruments. Limbs with reflux demonstrated in the saphenous veins, the deep veins, or the perforating veins as well as those with prior therapy by sclerotherapy, varicose vein surgery with or without episodes of deep venous thrombosis were excluded from the study.

It was found that nearly 10% of the limbs exhibited reflux in tributaries and not in the axial saphenous veins. The number of incompetent tributaries ranged from one to five per limb and the most prevalent were those to the greater saphenous vein or to the lesser saphenous vein or combinations of these. Among the named tributaries in the lower extremities, the posterior arch vein was most often incompetent followed by the anterolateral tributary vein of the thigh and then the medial accessory vein of the thigh.

The limbs examined tended to be, for the most part, CEAP classification 2 which is varicose veins. Only 14% were in class 3 which includes edema. The authors concluded that the data indicated that reflux confined to superficial tributaries is found throughout the lower limb and can be present without greater or lesser saphenous trunk or perforator or deep vein incompetence. This study shows that reflux can develop in any vein without an apparent feeding source detected by duplex examination.

COMMENTARY

Many believe that one of the sources of venous hypertension which produces dilation of telangiectasias, reticular varicosities, and varicose veins is failure of check valve function of perforating veins which is not detected by duplex examination. It has become increasingly obvious that duplex examination, while extremely valuable, does fail to detect some outward flow in perforating veins. When this fact is combined with knowledge that muscular compartment pressures regularly range from 150 to 300 mmHg during muscular contraction suggests that isolated superficial vein reflux can be derived from the venous hypertension produced by muscular contraction. That the present duplex Doppler instruments do not recognize the perforating veins is regrettable. Nevertheless, the source of the pressure which dilates and elongates subcutaneous veins should remain a mystery no longer.



ABSTRACT

In the second presentation from the laboratory of Labropoulos, it is recognized that there is controversy regarding the role of perforating veins in the development of severe chronic venous insufficiency (CVI). This study was designed to determine the duration and direction of flow in lower limb perforating veins in relationship to their location, diameter, and competency status of the superficial and deep veins.

Healthy volunteer examinations were compared with patient examinations in different grades of CVI. There were 30 limbs examined in 15 symptom-free volunteers and 103 limbs in 75 patients with CVI. Examinations were conducted in the sitting and standing positions, and flow velocity characteristics, number, and maximum perforating vein diameters were recorded. A perforating vein was considered incompetent when the outward flow lasted greater than 0.5 seconds.

A total of 581 perforating veins were found in the patients and only 106 in the volunteers. Twenty-eight percent (28%) of the perforating veins in patients were incompetent and none were incompetent in the volunteers. The number of perforating veins and the number of incompetent perforating veins per limb increased significantly with the severity of CVI. The mid-calf area had more competent and incompetent perforating veins in patients and the mean diameter of incompetent perforating veins in all of the chronic venous disease classes was significantly greater than that of competent perforating veins. Also, competent perforating veins tended to be larger with increasing severity of CVI and were significantly larger than in controls in the chronic venous disease classes of 4 through 6 which includes lipodermatosclerosis, healed, and open ulcers.

In this study, a subfascial perforating vein diameter of greater than 3.9 mm indicated incompetence and the subfascial diameter was found to be much greater than that of the vein at the fascial level. Bidirectional inward and outward flow was found more often in patients than in the controls, and most incompetent perforating veins had outward flow alone.

The authors conclude that the number of incompetent perforating veins and the diameter of both competent and incompetent perforating veins increases with the severity of Chronic venous insufficiency. Bidirectional perforating vein flow is more common in patients than in normal volunteers, and 77% of the incompetent perforating veins have outward flow alone. Perforating vein incompetence is most often associated with reflux in the superficial veins, indicating that deep venous reflux is rarely the primary cause of perforating vein insufficiency.

COMMENTARY

The data included in this carefully performed study are subject to interpretation. As indicated above, clearly varicose veins may arise from transmission of exercise compartmental pressure through the failed check valves of perforating veins. It is not surprising, therefore, that the stigmata of severe CVI in classes 4, 5, and 6 of the CEAP classification are found in association with large perforating veins. If one believes the very tenable hypothesis that leukocyte activation is found in association with the inflammatory changes of CVI, then the link between compartmental pressure, incompetent perforating veins, and subcutaneous and cutaneous skin changes is understandable. It becomes increasingly obvious that pure hemodynamics do not explain the skin and subcutaneous changes of CVI but that venous hypertension is simply one component in the equation that results in advanced CVI. The molecular basis for skin and subcutaneous tissue changes has yet to be worked out, but therapy of severe CVI rests on an increasingly strong foundation. That is, venous hypertension is transmitted through superficial reflux, and perforator vein outward flow and this can be modified by straightforward, simple surgical techniques combined with compression for the vast betterment of many patients. ivdfjjb1






NEW TRENDS IN THE SURGICAL AND ENDOVASCULAR RECONSTRUCTION OF LARGE VEINS FOR NON-MALIGNANT CHRONIC VENOUS OCCLUSIVE DISEASE
Alimi YS, Juhan C.
Current Opinion in Cardiology 1998; 13:375-83

COMMENTARY BY:
C. Vaughan Ruckley, MB, ChM, FRCSE
University of Edinburgh
Edinburgh, Scotland

The authors point out that considerable advances have been made in reconstructive venous surgery in the past two decades. They review the literature on superior vena cava (SVC) reconstructions and inferior vena cava and iliac vein reconstructions, and they add some useful data derived from their own experience. They base their discussions of superior vena cava occlusions on the classification scheme of Stanford and Doty:

Type I:
Stenosis (up to 90%) of the SVC with patency and antegrade flow of the azygos/right atrial pathway.

Type II:
More than 90% stenosis or occlusion of the SVC with patency and antegrade flow in the azygos/right atrial pathway.

Type III:
More than 90% stenosis or occlusion of the SVC with reversal of azygos blood flow.

Type IV:
Occlusion of the SVC and one or more of the major caval tributaries, including the azygos systems.

The authors report that when autogenous material is available, spiral saphenous vein graft is the best replacement. Where autogenous material is not available, externally supported PTFE continues to be the best conduit. Grafts with less than 10 mm internal diameter have poor patency because low flow results in thrombus deposition on the thrombogenic surface of the prosthesis. Although the authors do not make a specific recommendation, they report good patency rates obtained by the addition of brachial arteriovenous fistula. In types I and II, superior vena cava obstruction caused by benign disease, stents are recommended. Primary surgical treatment is preferred for types III and IV.

Selection of patients for iliocaval bypass is difficult. Good prognostic criteria are low-risk patients without significant reflux in the femoropopliteal veins with unaltered external iliac and common femoral veins suitable for a proximal anastomosis and a normal inferior vena cava or contralateral iliac vein used as outflow. Most have underlined the need for a pressure gradient. In the case of unilateral iliac vein occlusion, a "Dale" procedure (femorofemoral crossover saphenous vein transposition) is the first choice of the authors. (My training describes this procedure as a Palma procedure which shows it is probably time to get rid of eponymous nomenclature in phlebology).

When a saphenous vein is not available, a 12 to 16 mm diameter PTFE graft can be employed as a femorofemoral or femorocaval bypass. Arteriovenous fistula is also recommended to enhance flow in this group of bypasses. The authors emphasize the frequency of stenosis and/or compressions at the iliocaval junction and favor early treatment with angioplasty and Wallstent once the presenting thrombosis has been cleared with thrombectomy or thrombolysis.

COMMENTARY

This is a very useful review in a somewhat neglected area of vascular surgery. Certainly, clinical experience suggests that there are a number of patients severely afflicted with symptoms of chronic venous insufficiency in whom surgical and/or endovascular procedures should be considered. This is yet another area of vascular surgery where very close collaboration between the surgeon and the interventional radiologist is in the best interest of the patient. ivdfruc1




THE MANAGEMENT OF VENOUS ANEURYSMS OF THE UPPER EXTREMITIES
Volteas SK, Labropoulos N, Nicolaides AN
Panminerva Med 1998; 40:89-93

ABSTRACT AND COMMENTARY BY:
David Bergqvist, M.D., Ph.D.
Professor of Vascular Surgery
Uppsala University
Uppsala, Sweden

While venous aneurysms are rare and have been reported in all areas of the venous system, the most common location is in the lower extremities. The etiology in most cases is cryptogenic and thought to be due to congenital wall defect. There are also iatrogenic venous aneurysms as well as those caused by arteriovenous fistulae. The incidence is not known as all reports are based on single cases or small case series without the proper background population. They present as either a mass or as venous thromboembolism, the latter especially in patients with popliteal aneurysms. Venography, CT scan, MRI, and ultrasonography have all be used for diagnosis. Today, ultrasonography seems to be the method of choice.

From the literature, it seems that surgical treatment is often preferred to conservative treatment. Administration of anticoagulants does not seem to prevent pulmonary embolism substantially. The most frequently used and also successful technique is tangential aneurysmectomy with lateral venorrhaphy. Keeping the aneurysm and protecting the pulmonary circulation with caval filters has rarely been successful because of both local and distant complications. Aneurysms in the crural and superficial veins are treated best and simplest by ligation and/or excision.



COMMENTARY

This article is a review of a rare condition. Professor Nicolaides and his group are to be congratulated for their scrutiny of the literature for a collective view. Their 77 references include most of what has been written on the subject. One problem with collecting case reports is that we do not really know the true prevalence, but the aneurysms are certainly uncommon. This means that vascular surgeons will very rarely, if ever, see one which means no one can accumulate true experience. I myself have seen only two venous aneurysms and resected both successfully.

Today, duplex ultrasonography is the diagnostic method of choice and it definitely seems that surgical treatment is the treatment of choice in the majority of cases. The main treatment goal is to prevent pulmonary embolism which causes a high mortality in nonoperated patients. ivdfber1




THE VENOUS THROMBECTOMY: OBSOLETE OR FORGOTTEN?
 Lacroix H, Van Belle K, Nevelsteen A, Suy R.
Acta Chir Belg 1998; 14-17

ABSTRACT AND COMMENTARY BY:
Peter Neglen, MD, Ph.D.
Vascular Surgeon, River Oaks Hospital
Jackson, Mississippi

This paper describes three case reports of patients with iliofemoral thrombosis treated with venous thrombectomy and temporary arteriovenous fistula.

The first case had a remaining occlusion of the common iliac vein. Because of abundance of collaterals, the obstruction was left alone and no arteriovenous fistula was created. The patient did not fare very well. Because of this experience, a second patient with a remaining severe iliac vein stenosis following thrombectomy was corrected with balloon dilatation and insertion of a stent, and an arteriovenous fistula was created. This patient was completely asymptomatic two years later. The third patient had a patent, nonstenotic iliac vein, required only an adjuvant arteriovenous fistula, and was asymptomatic after one year.

The pertinent literature is reviewed in the discussion.

COMMENTARY

This study presents surgical thrombectomy as an alternative to conservative anticoagulation treatment in patients with iliofemoral venous thrombosis. I agree with the authors.

Obstruction of the common pathway of outflow from the lower extremity contributes substantially to the pathophysiology of severe postthrombotic disease especially when present in combination with reflux. In addition, persisting proximal obstruction frequently leads to dilatation of distal venous segments. This may render incompetent those valves which were previously in uninvolved distal segments. Therefore, early clot removal not only abolishes obstruction to outflow but protects the distal vein from progressive valvular insufficiency. These points are not generally recognized. At this time, there is growing agreement in the logic of reconstituting patency of the iliofemoral segment.

Methods of early clot removal include surgical thrombectomy or fibrinolysis. The efficacy of catheter-directed intrathrombus urokinase has been evaluated favorably in the Venous Registry. In the United States, it is considered the method of choice. Although only one prospective study exists assessing surgical thrombectomy versus anticoagulation, many single-arm prospective and retrospective studies have shown that surgical thrombectomy is a safe and effective method in selected patients. Today, when urokinase is unavailable in the United States and the efficacy and risks of tPA venous thrombolysis are untested, surgical thrombectomy is certainly an excellent alternative.

Treatment should not be performed in elderly, nonambulatory patient with limited life expectancy unless the limb is threatened. This is because the main objective is the prevention of subsequent postthrombotic disease. Regardless of the method of treatment, the earlier the therapy, the better the result. Surgery should always include a temporary arteriovenous fistula unless the clot is limited to the iliac segment and there is no stenosis following removal. If an intraoperative venogram shows obstruction of the iliac segment after thrombectomy, it is vital to perform a balloon dilatation and stent placement in the same setting. This surgery is well suited for performance in a dedicated interventional procedure room.

Venous thrombectomy is certainly not obsolete. Although it is perhaps not forgotten, it is not as popular today in the United States as it is in Europe. vdneg347




SAPHENOFEMORAL RECURRENCE: A FOLLOWUP STUDY AFTER 34 YEARS
 Fischer R, Linde N, Duff C, Jeanneret C, Seeber P.

ABSTRACT ONLY:
Reinhard Fischer, M.D.
St. Gallen, Switzerland

Aim:
Assessment of long-term recurrence rate after crossectomy (proximal ligation and division) of the greater saphenous vein.

Methods:
Between 1960 and 1967, crossectomy of the greater saphenous vein was performed on 602 patients by the same surgeon. At followup, 485 patients were deceased or had moved away and 40 were not able to follow up because of health problems or they lived too far away. A total of 77 patients (59 female, 18 male) were investigated clinically and with color-coded duplex ultrasonography (Acuson XP 10) 32 to 39 years (mean 34 years) after crossectomy. Recurrences were divided into four groups:

  1. Type A: No recurrence.
  2. Type B: Small connecting vessel at crossectomy site leading to a varicose branch.
    Type B1: Tortuous vessel or cord
    Type B2: Single vessel
  3. Type C: Connecting vessel not joining the crossectomy site.
Results:
Clinical investigation revealed 47% varicose recurrence. Recurrence diagnosed by color-coded duplex ultrasonography was seen in 60% of all patients: 42.4% Type B (17.6% B1, 24.8% B2) and 17.6% Type C.

Conclusions:
This long-term followup study confirms the recurrence rate after crossectomy published in the literature to date. With color-coded duplex ultrasonography, recurrences are detected more frequently than by clinical investigation. To our knowledge, a recurrence rate after a mean of 34 years has never been published. These results may serve as a basis for the upcoming studies on the causes and prevention of recurrence after correct crossectomy. vdfis347






RECURRENCE IN SPITE OF CORRECT CROSSECTOMY OF THE GREATER SAPHENOUS VEIN: NEOANGIOGENESIS (Krossenrezidiv der vena saphena magna trotz korrekter krossektomie: Neoangiogenese)
 Frings N, Tran VTP, Nelle A, Glowacki P
Phlebologie 1999; 28:144-48

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

The objective of this study was to assess the frequency of varicose recurrence after correct crossectomy (saphenous ligation and division) and to investigate the causes of recurrence. Correct crossectomy means resection of the proximal greater saphenous vein with interruption of all proximal tributaries and flush ligation of the saphenofemoral junction.

All 81 crossectomies (16% male, 86% female) (41 to 60 years) were done by the same surgeon under local anesthesia. The surgeon inspected the femoral vein 1 cm proximally and 1 cm distally to the saphenofemoral junction for additional tributaries. The saphenous vein was ligated with absorbable suture. If additional tributaries of the femoral vein were found in the immediate area, they were divided between ligatures. At the routine check three months' postoperatively, no incompetence was found at the former saphenofemoral junction.

The recent study examined the 81 crossectomies after four to five years with hand-held Doppler and color-coded duplex ultrasonography. In these 81 cases, the authors found no proximal incompetence in 54 (66.7%). However, an inguinal incompetence was found in 27 (33.3%). The latter group was further subdivided in a group of 12 (25.9%) with a small tributary of 1.4 to 4.7 mm in diameter. The other six cases (7.4%) had proximal connection greater than 5 mm in diameter. There was no correlation between deep venous insufficiency and saphenofemoral recurrence. The first subgroup was treated either with sclerotherapy or with phlebectomy. The second subgroup had reoperation.

In all six reoperated cases, the origin of the recurrence was found to be at the exact site of the former ligation. It was the starting point of a system of fragile fine vessels surrounded by lymph nodes. Three of the six nodes were examined histologically. Between the lymph nodes there were segments of relatively normal veins with a muscle layer. Between these, there was a rich network of ectatic venules without muscle layers. Histologically, they appeared to have proliferated.

The authors conclude that the cause of the recurrence must be neoangiogenesis since they see no other plausible cause after correct crossectomy. They are now attempting a prospective, randomized study with 500 cases divided into groups with different techniques of ligation with the aim of preventing neoangiogenesis.

COMMENTARY

Many phlebologists believe that proximal recurrence cannot occur after correct crossectomy. These authors have found that it can and their figures are compatible with the results published elsewhere in the limited literature on recurrence after correct crossectomy. Jeanneret observed a total recurrence rate of 24.4%, Kluess 8%, and Leu 6.5%.

Establishing the incidence of recurrent reflux is the first contribution of this study. The second is that the investigators found that histology of the site close to the former ligation is compatible with concept of neoangiogenesis. The third contribution is the sophisticated and comprehensive discussion of the different possible causes of recurrence (in German).

The authors conclude that proliferation of the endothelium from the saphenous stump is the cause of recurrence after correct crossectomy. However, there are a number of alternative causes such as angiogenesis from the mini-thrombus on either the femoral or saphenous side of the ligature, preexisting microscopic veins, the vasa vasorum, vascularization of the vascular wall irritated by absorbable or nonresorbable ligatures, or irritated tissue due to scar formation after excessive exposure.

Recurrence after correct crossectomy is one of the frontiers of investigation in present-day varicose vein surgery. In this research, biochemical, histological and anatomical aspects will need to be considered. In addition, Netzer's dogma of the proliferation-protective function of existing varicosis and Hach's concept of recirculation in varicose veins will also need to be taken into account. vdfis348




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


Superficial Thrombophlebitis of the Legs: A Randomized, Controlled Followup Study
Belcaro G, Nicolaides AN, Errichi BM et al.
Angiology 1999; 50(7):523-29

In this study, after three and six months, the incidence of superficial thrombophlebitis extension was higher in patients treated with elastic compression than in those with saphenous ligation. Stripping of the affected veins was associated with the lowest incidence of thrombus extension but there was no significant difference in deep venous thrombosis incidence at three months among the treatment groups.


Outpatient Treatment of Deep Vein Thrombosis: Translating Clinical Trials into Practice
Dunn AS, Coller B
Am J Med 1999; 106:660-69

This article defines essential components of an outpatient program for treatment of deep venous thrombosis. This includes appropriate patient selection, adequate patient education, daily followup, and easy access to expert consultation.


How to Help Patients with Restless Legs Syndrome: Discerning the Indescribable and Relaxing the Restless
Evidente VGH, Adler CH
Postgrad Med 1999; 105:59-74

These authors suggest a number of pharmacologic and nonpharmacologic treatments but do not list venous insufficiency as the cause of the syndrome.


Endoscopic Subfascial Perforating Vein Ligation: Its Complementary Role in the Surgical Management of Chronic Venous Insufficiency
Padberg FT Jr.
Ann Vasc Surg 1999; 13(3):43-54

Beautiful anatomic drawings accompany this report and will be of interest to surgeons who participate in SEPS procedures.