RISK FACTORS ASSOCIATED WITH THE FAILURE OF A VENOUS LEG ULCER TO HEAL
 Margolis DJ, Berlin JA, Strom BL
Arch Dermatol 1999; 135:920-26

ABSTRACT AND COMMENTARY BY:
Robert L. Kistner, MD
Straub Clinic and Hospital
Honolulu, Hawaii

A total of 260 cases were culled from 433 consecutive patients treated for chronic leg ulcers in the Cutaneous Ulcer Center of the Department of Dermatology at the University of Pennsylvania Medical Center in Philadelphia. The purpose of the study was to describe risk factors associated with failure of a venous leg ulcer to heal in patients treated with a limb compression bandage.

The 260 cases were chosen for the study if they had a wound of the skin located in the gaiter area of the limb, if they had a history of lower leg edema that improved with leg elevation, other cutaneous findings of venous disease such as venous blush/flare, varicose veins, or venous valvular incompetence, and a nonischemic ankle brachial index defined as 0.70. Exclusion criteria consisted of life expectancy less than 24 weeks, recent use of immunosuppressives, history of or currently active ulcer disease consistent with cutaneous vasculitis, pyoderma gangrenosum, or other neutrophilic dermatoses.

A total of 28 risk factors were outlined for study. All patients were evaluated by one of the authors according to a standard protocol. Treatment consisted of a multilayer high-compression bandage changed weekly or twice weekly. Evaluation continued until the wounds healed, or for 24 weeks, whichever came first. An extensive description of the statistical analysis is given in the paper. This analysis was sophisticated consistent with the authors' background and strong interest in biostatistics.

Results indicated that 92 wounds (35%) failed to heal within 24 weeks. Of the 28 risk factors studied, ten were statistically significant. These included increased wound area of ulcer, increased duration of ulcer, decreased ankle brachial index, increased number of ulcers, non-Caucasian ethnicity, history of venous ligation or stripping, inability to walk one block, wound margin undermined, > 50% of wound covered with fibrin, and wound debrided surgically. It was also noted that some factors acted in a synergistic fashion, notably ulcer size and duration, in preventing healing within 24 weeks.

COMMENTARY

The stated purpose of this study was to describe risk factors associated with failure of healing of venous ulcers. The authors identified several findings related to the skin such as the size of the ulcer but did not study the basic facets of the venous disease itself. In my opinion, the real factors that lead to failure to heal and early recurrence lie in the venous disease itself, which is the underlying cause of the skin problem, rather than in the effects of the venous problem such as ulcer size or duration. These latter are effects of the process, not true risk factors. As this report points out, however, certain attributes of an ulcer can provide predictability about the length of time it may take a particular treatment to achieve healing. Healing venous disease lies in the causes of it, such as the underlying case of a venous abnormality (whether reflux or obstruction) and where it is located in the venous tree.

If we are to learn the critical factors that cause the complications of chronic venous disease such as the venous ulcer, definitive diagnosis of the venous system is required. First of all, the lesion must be identified to be of venous cause. Secondly, the venous problem must be classified as to cause and anatomic distribution of altered physiology.

An adequate workup requires, at a minimum, duplex scanning of each case. This can be supplemented by selective use of physiologic testing with pressures and plethysmography (in some cases venography) to define the true problem. In recent years, these elements have been presented in the venous literature to provide uniform methods of evaluating chronic venous problems. The CEAP classification system was devised in 1994 and has been promulgated around the world.1,2 Dr. John Bergan was a central author in this classification system which set the standard for diagnosis and defined the important elements of chronic venous disease. The system consists of the etiology of the clinical problem, the presence of reflux and obstruction in the veins, and the anatomic distribution of these changes among the segments of the venous tree.

In a case of mixed ulcers, such as those with both arterial and venous insufficiency, the workup needs to identify the exact changes in both systems.

In my opinion this article lacks the criteria to be titled "venous" leg ulcers because it addresses healing of extremity ulcers by compression therapy without defining the precise etiology of the wounds. Accurate diagnosis of venous problems in order to develop a scientific approach to management is essential. This requires a change in thinking from the conventional concept of the postphlebitic leg which is diagnosed, in large part, by its appearance. There must be insistence on accurate objective testing of the venous system by imaging and physiologic tests to define the true venous problem in each case. In order to accomplish this change in thinking, it is important to publish across specialty lines with vascular experts presenting their data in the dermatologic and general medical literature and vice versa. ivdfkis1

REFERENCES

1. Classification and grading of chronic venous disease in the lower limb: A consensus statement. Vasc Surg 1996; 30:5-11.

2. Porter JM, Moneta GL, and International Consensus Committee on Chronic Venous Disease: Reporting standards in venous disease: An update. J Vasc Surg 1995; 21:635-45.




A MULTICENTER STUDY, PHASE I EVALUATION OF CRYOPRESERVED VENOUS VALVE ALLOGRAFTS FOR THE TREATMENT OF CHRONIC DEEP VENOUS INSUFFICIENCY
Dalsing MD, Raju S, Wakefield TW, Taheri S.
J Vasc Surg 1999; 30:854-66

COMMENTARY BY:
Csaba Dzsinich, MD
Budapest, Hungary

This Phase I study of cryopreserved venous valve segments attempts to determine whether function and patency persists during the first six months after implantation. As the incidence of chronic venous insufficiency in the United States has been estimated to be as high as 6 million individuals with an annual increase of 800,000 per year, this condition constitutes one of the leading problems in health care. Valvular incompetence, caused mainly by the postphlebitic syndrome, is supposed to occur in approximately 2 million people. About 10% of these are potential candidates for surgical valve repair or replacement. This is 50,000 patients who have no proper autologous source for valve transposition or transplantation. Therefore, the need for an alternative valve substitute is obvious.

Cryopreserved venous allografts supported by adjunctive AV fistula have proven themselves in a greyhound model of deep venous insufficiency in Dalsing's early experience. Based on this, human cryopreserved superficial femoral venous segments appeared to be promising for clinical use. Also, there is no significant difference in size or biomechanical characteristics encountered in such allotransplantation.

Ten patients with end-stage venous insufficiency (CEAP classes 4, 5, and 6) of the legs were selected for this clinical trial. A carefully written protocol defined all aspects of the trial. Exclusion criteria included age younger than 18 years, pregnancy, occlusion of iliac veins, and severe comorbid conditions such as congestive heart failure, vasculitis, peripheral arterial occlusive disease, and morbid obesity. Preoperative evaluation consisted of detailed inquiries into the patient history followed by venous duplex scanning, ascending phlebography, proper ABO blood group matching with the tissue to be transplanted and evaluation of coagulation factors.

Only patients with severe Kistner grade 3 to 4 reflux were selected for valve replacement. Venous refill time (VRT), ambulatory venous pressure (AVP) and venous filling time (VFT) were recorded, and the data evaluated statistically. These data help to confirm the severity of venous insufficiency and could be compared to the postoperative situation. At surgery, single-valve cryopreserved venous segments were implanted, either into the superficial femoral or the popliteal veins of the recipient below reflux into normal veins. Diameters of recipient and allograft veins were meticulously matched. Nonabsorbable, interrupted 5-0 to 7-0 sutures were used. Proof of valvular competency was mandatory after thawing of the valve. In two patient limbs, complimentary AV fistulas were constructed. Seromas developed in one-third of the patients. All patients were anticoagulated for six months and prothrombin time controlled at one-, three-, and six-month intervals. Data were recorded and collected from all participating centers and statistically evaluated for patient survival, graft patency, and complications.

Eight of ten grafts were patent at three months and seven have remained patent after six months. Clinical stages of venous insufficiency improved in 55% of the patients.



The overall conclusion of this study is that the results are a bit less impressive than those achieved with autologous axillary vein transplantation. Use of cryopreserved allografts is indicated when no autologous material is available. In this reviewer's opinion, this paper is a milestone in research of proper venous valve replacement. ivdfdzs1




COMPARISON OF COSTS AND HEALING RATES OF TWO FORMS OF COMPRESSION IN TREATING VENOUS ULCERS
 DePalma RG, Kowalleck D, Spence RK, et al.
Vasc Surg 1999; 33(6):683-90

ABSTRACT AND COMMENTARY BY:
Marc Cairols, MD. PhD, FRCS
Barcelona, Spain

Any improvement in treating venous ulceration is always welcome as venous ulcers are a common and cumbersome problem in vascular surgery. These authors believe the present study proves that the new adjustable dressing, the Thera-Boot (CircAid Medical Products, Inc., San Diego, California) leads to faster healing and lower treatment costs when compared to traditional Unna boots.

In order to prove this hypothesis, a multicenter, prospective, parallel-group study was conducted. Six centers were involved. Inclusion criteria were straightforward: Patients older than 18 years with duplex-documented unilateral ulceration of venous origin willing to participate.

Exclusion criteria were more extensive: Ulcers larger than 5 cm in diameter, physician judgment that the ulcer would not heal with conservative treatment, poor underlying general health and venous surgery within the last month. Also, if the investigator felt that the patient could be better treated by other methods, they were excluded. Calculations to evaluate costs were made according to time/cost assigned to the physician and nurse, the number of visits, and the materials used. In all patients, an initial evaluation was done and randomization made to either the Unna boot or Thera-Boot. At each visit, the ulcer was cleansed and debrided (if appropriate) and a tracing of the ulcer was made on a clear film. Results were reported as mean standard deviation. Statistics were calculated using the student's t-test. Data were analyzed on an intention-to-treat basis.



A total of 38 patients were enrolled but only 28 completed the study (Unna boot 11, Thera-Boot 17). Both groups were comparable in age, ulcer size, duration of ulceration and CEAP classification. Three patients were in treatment at the time the cost analysis arm of the study was halted and it is not clear which group they were in. Physician mean time spent in the Unna boot group was significantly greater than the time spent in the Thera-Boot group (2.63 2.00 hours versus 1.46 0.81 hours). The time spent by the nurse was the same in each group.

COMMENTARY

Apparently improvement achieved by this new method of treating longstanding, nonhealing leg venous ulcers is based on dressing adjustment and not compression. The authors stated that the Unna boot loses compression rapidly while the Thera-Boot can be adjusted as frequently as necessary by the patient to maintain compression. According to the authors, this is the major reason for the observed beneficial healing trend. Although not statistically significant, there was a faster rate of healing in the Thera-Boot group.

It is difficult to compare healing rates as the initial ulcers have wide variations in size and duration. Larger ulcers may represent more severe disease and worse skin quality. Time spent by the physician was significantly less in the Thera-Boot group. This is explained by the authors as the result of combining less time per visit. The physicians did have to apply the Unna Boot but patients could apply their own Thera-Boot. There were also fewer clinic visits in the Thera-Boot group because of faster ulcer healing. Therefore, the main advantage with regard to cost is the shorter physician time spent with each patient. Knowing the cost of treating venous ulcers in the outpatient department makes this study different from others where inpatient and outpatient costs were mixed.

Nevertheless, some points can be made. When data from different centers is analyzed, heterogeneity in quality of care is expected even though we all agree that specialized leg ulcer services have a positive influence on outcome of treatment.1 Moreover, inclusion criteria in this study were so loose that a significant number of patients may have been denied potential benefit from this innovative treatment. I feel that a recent venous operation was a particularly restrictive exclusion. Many patients with nonhealing vein ulcers are operated precisely to effect healing. This exclusion criteria is understood if a homogeneous group of patients is desirable for the study. However, as a general statement, vein surgery plays an important role in treating venous ulceration.2 A discussion of this by these surgeons would have been appreciated.

An exclusion criteria peculiar to this study was if the "investigator felt that other methods are better than the one used in the study". This makes it appear as though the Thera-Boot is not a good therapy for an undisclosed number of patients. In any case, the statement that all data were calculated on an "intention-to-treat basis" is not supported in this study.

Lower cost is an undeniable advantage in all medical treatments. However, calculating expenditure in a particular vein clinic may not be reproducible in other outpatient environments. Therefore, this may not be considered a strong endpoint. In some outpatient clinics, such as ours, skilled nurses have a more important role in dressing these patients. The physicians visit with them only when required.

It would be interesting to know the relationship between the degree of deep reflux and healing. It is generally accepted that popliteal reflux may be an indicator of a poor response to therapy of venous ulceration.3 Another issue of interest is the recurrence rate. Most of us agree that management of venous ulcers should be regarded as a lifetime process. Thus, information as to how many times this therapy can be applied should have been discussed. Information regarding comfort, absorption quality, ease of application and removal are also relevant.

I agree with the conclusions of a prior consensus document enumerating the properties of a beneficial dressing. These include low cost and satisfactory results. A supervised program of self treatment is a good way to save money but whether the Thera-Boot fulfills requirements for all kinds of venous leg ulcers and different clinical regimens remains to be seen.

REFERENCES

1. Ghauri AS, Nyamekye I, Grabs AJ, et al. Influence of a specialised leg ulcer service and venous surgery on the outcome of venous leg ulcers. Eur J Vasc Endovasc Surg 1998;16:238-244.

2. Bello AM, Scriven M, Naylor AR, Bell PR, London NJ. Vascular Surgical Society of Great Britain and Ireland: Role of superficial vein surgery in treatment of venous ulceration. Br J Surg 1999; 86:701-2.

3. Brittenden J, Bradbury AW, Allan PI, Prescott RJ, Harper DR, Ruckley V. Popliteal vein reflux reduces the healing of chronic venous ulcers. Br J Surg. 1998; 85:60-2.






LONG-TERM RESULTS OF TREATMENT OF BENIGN CENTRAL VENOUS OBSTRUCTIONS UNRELATED TO DIALYSIS WITH THE EXPANDABLE Z-STENTS
 Peterson BD, Uchida BT
JVIR 1999; 10:757-66

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

Central venous obstruction has emerged as a significant therapeutic problem.

During a ten-year period, 19 patients received Z-stents for treatment of benign symptomatic central vein obstructions. There were seven in the superior vena cava, ten in the inferior vena cava, and two with Budd-Chiari syndrome. The patients (16 males) averaged 53 years in age (16-72). Fourteen were stented primarily and five had thrombolysis performed with urokinase before dilatation and stenting. All procedures were successful primarily.

Resolution of symptoms took three days in upper extremity obstruction, seven days in lower extremity obstruction and 7 and 14 days, respectively, for the Budd-Chiari patients. The only complication was operation for one neck hematoma due to a punctured jugular vein. Twelve patients died after a mean interval of 11 months (1-37). Recurrence was treated with PTCA in one and stenting in one. At death, the primary and secondary patencies were 83% and 100%, respectively. Six patients were alive at followup at 71.6 months (24-96). One patient occluded the portal vein which was successfully reopened and re-stented. In survivors, there was a pattern of patency as in the deceased, 83% and 100%, respectively. One patient was lost to followup.

COMMENTARY

This is another endovascular contribution from the Dotter Interventional Institute in Portland, Oregon. Although small, this series shows impressive results when stenting is used for benign central venous stenoses. As always, with endovascular techniques, one must be prepared for re-intervention to obtain a high secondary patency. From the perspective of the patient, this is obviously better than a major surgical procedure but any intervention carries risks. In these types of obstructive lesions, symptoms are dramatic and the effect of treatment, if successful, is often very evident. An interesting observation was the difference in times of resolution of congestive symptoms as detailed above.

Although the lesions were benign from a pathologic anatomic point of view, the patients' diseases were certainly not benign as seen in the high mortality at a fairly young age. The authors treated 19 patients over a ten-year period which again emphasizes the infrequency of such lesions. It is certainly motivating to centralize this treatment so that total knowledge can be increased. The authors' plea for a randomized study can be supported but because of the rarity of the condition, there will be a number of logistical problems.




USE OF IPSILATERAL GREATER SAPHENOUS VEIN AS A VALVED TRANSPLANT IN MANAGEMENT OF POSTTHROMBOTIC DEEP VENOUS INSUFFICIENCY: LONG-TERM RESULTS
 Cardon JM, Cardon A, Joyeux A, et al.
Ann Vasc Surg 1999; 13:284-89

ABSTRACT AND COMMENTARY BY:
Elna M. Masuda, MD
Straub Pacific Health Foundation
Honolulu, Hawaii

This is a retrospective review of the authors' experience with venous valve transposition of the greater saphenous vein (GSV) to the superficial femoral vein (SFV) in the treatment of pain and ulceration from postthrombotic disease.

The technique described deviates slightly from previous reports of valve transposition. Prior studies have shown that when the SFV is transected and anastomosed in an end-to-side fashion to the side of the GSV, the competent valve of the GSV will take over and result in healing of ulcers and resolution of pain. Good to excellent results have been achieved in approximately 40% of cases with a ten-year followup period.1 In the present series, the technique is modified and the divided upper portion of the GSV with competent valve is anastomosed in a functional end-to-end fashion to the SFV. To avoid mismatch between the two vessels, the GSV is joined to the side of the SFV and the latter is divided proximally (Fig.1).

Results for 16 patients were reported with a followup of two to ten years (mean 4.5 years). Indication for surgery was ulceration in 9 of the 16. The remainder had pain but no ulcers. At a mean of 4.5 years, 11 of 16 patients (69%) showed healed ulcers and/or resolution of pain. For the nine patients with ulceration, 55% had successful resolution of ulcers without recurrence at approximately 3.5 years.

The authors concluded that venous valve transposition of the GSV to the SFV is successful in eliminating ulceration in 55% of patients at 3.5 years. These results were increased to 84% when secondary intervention such as eliminating superficial venous reflux was added to the treatment in the followup period.



COMMENTARY

Prior studies of venous reconstructive surgery demonstrate the feasibility and long-term success of restoring valvular function. Two general categories exist, depending on whether a valve with intact leaflets is present.

  1. If a valve is intact but leaflets do not coapt normally, the pathology is primary valvular insufficiency and surgical management consists of valvuloplasty (or valve repair).

  2. If a valve is absent (aplasia) or destroyed by prior venous thrombosis (secondary valvular insufficiency), reconstruction consists of transposing the vein onto an adjacent segment with a functioning valve, or transplantation of a valve from another site such as the axillary vein or homograft.
In this series, the authors describe transposition of the GSV and SFV systems in patients with secondary venous insufficiency and they modify the procedure from prior reports by changing the conduit being transposed. They state that the advantage is a better match between the smaller-diameter GSV and the much larger SFV. Although their technique is described as "novel," it does not appear to show much advantage over the original technique described in 1979.2 The early reports avoid mismatch by placing the end of the SFV to the side of the GSV and this seems to resolve any mismatch problem. Possibly the greatest advantage from this study is that the dissection of the SFV is simplified and limited to a shorter segment.

However, the most important contribution made by the authors is the necessity of close followup and correction of any new reflux. It may be as simple as ligation and stripping of the lesser saphenous vein or interruption of newly developed perforator veins. With such diligent surveillance and appropriate correction of reflux as it arises, they were able to increase the success rate of eliminating ulcers and pain to 84%, a commendable outcome in deep venous valve surgery.

REFERENCES

1. Masuda EM, Kistner RL. Long-term results of venous valve reconstruction: A 4- to 21-year followup. J Vasc Surg 1994; 19:391-403.

2. Kistner RL, Sparkuhl MD. Surgery in acute and chronic venous disease. Surgery 1979; 85:31-43.




AXILLARY VEIN TRANSFER IN TRABECULATED POSTTHROMBOTIC VEINS
 Raju S, Neglen P, Doolittle J, Meydrech EF
J Vasc Surg 1999; 29:1050-64

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

Dr. Raju and associates have a vast experience in treating patients with valve reconstruction between 1979 and 1997. The focus of this paper is a subset of 81 patients (83 limbs) who underwent an axillary vein valve transfer to a trabeculated recipient vein. This subset was compared to 82 patients (82 limbs) who underwent axillary vein valve transfer to nontrabeculated vein segments.

In the study group, 90% of patients underwent surgery for recurrent stasis dermatitis or ulceration with 62% of the limbs having active ulcers at the time of surgery. A total of 102 axillary vein valve transfers were performed. Nineteen (19) patients had two axillary vein transfers in the same procedure. In another 19 patients, an additional deep venous procedure such as valvuloplasty or ligation of a poorly canalized superficial femoral vein was performed. Additional procedures included saphenous vein ligation or stripping in 55 limbs, perforator ligation in 24 limbs, and both procedures in four limbs. Dr. Raju notes that approximately 40% of axillary valves are incompetent in situ. "Bench repair" was performed in 32 axillary valves transferred to trabeculated veins using a variety of techniques.



Patient evaluation was extensive and included foot/arm pressure differentials, ambulatory venous pressures, air plethysmography, and duplex imaging. Preoperative ascending and descending venography was also performed.

Results in this large group of patients with difficult trabeculated veins were excellent. There were no operative deaths and no pulmonary emboli. Deep vein thrombosis occurred in 4%, hematoma/seroma in 6%, superficial wound infection in 6%, and deep wound infection in 2%. Patency was 96% at 90 days. The cumulative patency rate of axillary vein valve transplants to trabeculated recipient veins was 83% at ten years. The ulcer-free rate was also greater than 60% at ten years. Hemodynamically, venous filling time and venous filling index improved significantly after surgery. However, ambulatory venous pressure measurements did not show significant post exercise pressure or percentage decreases. The majority of patients had significant improvement in both pain and swelling postoperatively.

COMMENTARY

This is a well-written paper with a large amount of data which is difficult to summarize briefly here. Of particular importance and interest are the descriptions of Dr. Raju's techniques which are alone worth reading.

The authors emphasize the need for frequent intraoperative repair of the transferred axillary vein valve and correctly state that it is best done while distended with blood. I suspect there may be an issue with semantics, however. "Transcommissural" (as defined by Dr. Raju), "external," and "closed" valvuloplasty are, in effect, the same procedure. Illustrations in other contributions by Dr. Robert Kistner, Dr. Thomas O'Donnell, Dr. Peter Gloviczki, and Dr. Seshadri Raju all show the repair sutures narrowing and shortening the angle or the valve commissure and cusp sinus.

Regardless of the semantics, however, Dr. Raju and his colleagues have produced enviable results and anyone treating chronic venous insufficiency should become familiar with this excellent report. vdwel043




STRUCTURAL CHANGES OF THE CRURAL FASCIA IN PATIENTS WITH ADVANCED CHRONIC VENOUS INSUFFICIENCY AND CHRONIC, RESISTANT-TO-THERAPY VENOUS ULCERS (in Polish)
 Staubesand J, Li Y
Przeg Fleb 1998; 6(1):5-22

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

The aim of this article is to compare structural changes of the crural fascia of 27 patients with chronic venous insufficiency (CVI) with 24 subjects with healthy veins. The structural changes were investigated by electron microscopy. In a sample of 24 subjects with healthy veins, the collagen fibrils in the superficial layer of the crural fascia were arranged strictly in bundles running in various directions in space. In 27 patients with CVI, (Hach stage III), normal arrangement of collagen within the fascia was completely lost. There was a tight, disordered network of fibrils which were themselves sometimes abnormal in appearance. The authors call these changes "fascial insufficiency" and postulate that the ultrastructural basis of fascial insufficiency may be the cause of chronic compartment syndrome which may lead to treatment-resistant crural ulcers.

The authors suggest that these results explain why paratibial fasciotomy may ameliorate leg pain and promote healing of treatment-resistant crural ulcers. Release of pressure in the flexor compartment of the leg by opening the fascial sheath initiates improvement in venous return and facilitates the restoration of normal microcirculation, according to these investigators. They suggest the following relationship: Disorders of the microcirculation due to chronic venous insufficiency damage the fibroblasts which are responsible for the synthesis and metabolism of collagen fibrils. If regulation of the cell is lost, this leads to fascial insufficiency which is responsible for increase in ambulatory pressure within the muscular compartments of the leg.

COMMENTARY

The finding of single smooth muscle cells in the superficial layer of crural fascia is very interesting. The authors suggest that tension in the fascia is not only a passive process but may be actively modified by smooth muscle cells. These investigations are very interesting and show a new pathophysiological point of view of CVI and a new of way of treating resistant crural ulcers. In my opinion, the suggestion that chronic compartment syndrome is responsible for incurable CVI is not proven. On the other hand, these investigations show ultrastructural changes of deep crural fascia. Perhaps in the planning of surgical treatment of CVI, we must consider not only reduction of reflux in the deep venous system but also paratibial fasciotomy.




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


Calman, Venous Surgery, and the Vascular Trainee
Turton EPL, Whiteley MS, Berridge DC, Scott DJA
J. R. Coll Surg Edinb 1999; 44:172-76

After the advent of changes following the Calman report and the implementation of Vascular Surgery Society recommendations, it was found that "despite the participation of trainees in specialized vascular units, current training schedules fail to cover the field of venous surgery adequately."