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 using 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 this group, the authors found no proximal incompetence in 54 cases (66.7%). However, an inguinal incompetence was found in 27 (33.3%). The latter group was subdivided into a group of 21 (25.9%) with a small tributary of 1.4 to 4.7 mm in diameter, and 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






DOES A DOUBLE LONG SAPHENOUS VEIN EXIST?
 Ricci S, Caggiati A.
Phlebology 1999; 14:59-64

COMMENTARY BY:
J.-J?r?me Guex, MD
Phlebology and Vascular Medicine
Nice, France

This study was done on 676 limbs with any grade of chronic venous insufficiency and some without any venous problems. A total of 610 greater saphenous veins not previously treated were found. Duplex ultrasound was the sole technique used in the study. The authors used the following criteria: Reflux lasting more than one second and a venous diameter > 2 mm.

To avoid confusion present in many previous articles (the paper contained an extensive and useful reference list), the authors defined the greater saphenous vein as the "Egyptian eye" as stated by Lesmasle et al.1 By this, they mean that the greater saphenous vein is enclosed in the saphenous compartment between the muscular fascia and a more superficial fascia (saphenous fascia). These fascia appear on the duplex ultrasound screen as two white lines surrounding a black dot; thus, the name "eye." All other more superficial veins are tributaries. At the femoral level, the authors described five different patterns and indicated their respective frequencies:

  1. Type A (317 cases, 52%): One greater saphenous vein, no large tributary. Thirty-two percent (32%) of these LSVs were entirely incompetent at the thigh.

  2. Type B (6 cases, 1%): True duplication of the GSV, with 2 veins in the saphenous compartment.

  3. Type C (159 cases, 26%): One GSV associated with a large superficial tributary (false duplication). In 44% of these cases, there was reflux in the proximal portion of the GSV and the tributary. There were no cases of isolated reflux in the tributary.

  4. Type D (61 cases, 10%): Cases with a second "eye" very close to the saphenofemoral junction which was the termination of the anterior superficial accessory saphenous vein. There was only one GSV "eye" distally. The superficial accessory saphenous vein was incompetent in 30% of cases.

  5. Type E (67 cases, 16%): Similar to Type C without any visible GSV below the anastomosis with a superficial tributary (this duplex ultrasound does not detect veins < 1 mm). Forty-five percent (45%) of these systems were incompetent. The authors also reported other interesting findings in the calf.
COMMENTARY

This article is of great importance because a proper identification of the greater saphenous vein is necessary to avoid inadequate surgery, useless strippings, and consequent recurrences. It would have been preferable to avoid the term "long saphenous vein" because the acronym (LSV) can be confused with the acronym of the lesser saphenous vein (LSV). More preferably, the terms short saphenous vein (SSV) and greater saphenous vein (GSV) should be used.

There are many therapeutic applications of this study, and can be classified as strategic and technical.

Strategically, most clinically obvious varices are subdermal and not intrafascial varices. This article indicates their relative frequencies and reports that the GSV trunk proximally may or may not be incompetent. We want to add that it is thought that GSV reflux, when it exists in that configuration, is related to an overload or venturi effect in the underlying varicosities. Treatment of the extrafascial varices will often suppress it (an analogous observation has been made regarding deep reflux by Bergan et al.2). Stripping the GSV when the trunk is competent and the varicose veins are more superficial will obviously lead to important recurrences and waste a possible spare part. When both the trunk and a superficial tributary are incompetent, the treatment of both is obviously necessary. The results of this study plead for an "a la carte" treatment.

Technically, this article is yet more proof of the need for duplex ultrasound before the treatment of varicose disease. The continuous-wave Doppler is inaccurate because it demonstrates reflux but does not indicate depth. We can also draw some therapeutic applications: Sclerotherapy can be applied to subdermal varices when intrafascial varices are more accurately treated with ultrasound-guided sclerotherapy. The same remark applies to "Muller's ambulatory phlebectomy." This technique is discussed for subfascial varices.

Finally, the authors have precisely answered the question of their title: A true double greater saphenous vein is very rare. However, many other confusing patterns exist and they are very well described in their article. ivdfgue1

REFERENCES

1. Lemasle P, Uhl JF, Lefebvre-Villardebo M, Baud JM. Proposition d'une d?finition ?chographique de la grande saph?neurology et des saph?nes accessories a l'?tage crural. Phl?bologie 1996; 49:279-86.

2. Walsh JC, Bergan JJ, Beeman S, Comer TP. Femoral venous reflux abolished by greater saphenous vein stripping. Ann Vasc Surg 1994; 8:566-70.






PERFORATION-INVAGINATION (PIN) STRIPPING OF THE LONG SAPHENOUS VEIN REDUCES THIGH HEMATOMA FORMATION IN VARICOSE VEIN SURGERY
 Kent PJ, Maughan J, Burniston M et al.
Phlebology 1999; 14:43-47

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

This group from the St. James University Hospital in Leeds, United Kingdom has performed an elegant study comparing thigh hematoma formation in patients undergoing stripping of the long saphenous vein by conventional stripping or by PIN stripping. This was done by evaluating the extent of the thigh hematoma using radioisotope imaging with labeled red blood cells before and six hours after surgery. A total of 14 patients undergoing bilateral stripping were included. The authors concluded that PIN stripping resulted in significantly decreased hematoma formation compared to standard stripping.

COMMENTARY

PIN stripping, described by Oesch in Berne, has become one of several modifications designed to improve results after stripping of the greater saphenous vein. In this study, PIN stripping failed in 4 of 14 patients (29%). The technique was compared with standard stripping utilizing a disposable stripper fitted with a 9 mm olive.

There are many methods which have been described to decrease hematoma formation. When I was a resident more than 35 years ago, my tutor, Albert Broom? in Sweden attached a long gauze to the head of the stripper for internal compression. John Bergan soaks the gauze in lidocaine-adrenaline to achieve pharmacologic constriction of the bleeders. Many surgeons prefer to place a firm bandage on the leg before they perform the stripping.

At the 3rd Pacific Vascular Symposium on Venous Disease held in Hawaii in November 1999, Yasuhiro Shimizu from Japan presented a new invagination stripper for selective stripping of the long saphenous vein. This device addressed some of the problems noted with the original PIN stripper. In the present study, perhaps it was a little unfair to standard stripping to use such a large olive (9 mm) since there are smaller sizes available.

There are also other new developments in the treatment of an incompetent saphenous vein. At the annual meeting of the American Venous Forum in February 2000, promising results of the Closure method (VNUS ) were presented. This uses a radiofrequency probe to obliterate the saphenous vein. For those who advocate preserving the saphenous vein, Lane from Australia described his vein cuff for external valvular support several years ago. While this was never approved for use in the United States, W. L. Gore & Associates are working on a similar principle which may soon be available for clinical application. vdekl068






HEALING RATES AND COST EFFICACY OF OUTPATIENT COMPRESSION TREATMENT FOR LEG ULCERS ASSOCIATED WITH VENOUS INSUFFICIENCY
 Marston WA, Carlin RE, Passman MA et al.
J Vasc Surg 1999; 30:491-98

ABSTRACT AND COMMENTARY BY:
Gregory L. Moneta, MD
Professor of Surgery
Division of Vascular Surgery
Oregon Health Sciences University
Portland, Oregon

The authors report results of a prospective but essentially anecdotal study of compression therapy for the healing of venous ulcers. From July 1995 to July 1998, patients with venous ulcers were treated with either three- or four-layer compression bandages or Unna boots. Three-layer bandages were used in the case of marginal arterial insufficiency (ankle brachial index between 0.50 and 0.80).

A total of 217 patients (mean age 61 years) with 252 venous ulcers were treated. Of these, 52% were male, 19% had morbid obesity, and 14% had diabetes. The average ulcer size at presentation was 24.6 cm2. Approximately one-third of the ulcers were less than 5 cm2, one-third were between 5 and 20 cm2, and another third were greater than 20 cm2. The ulcers had been present an average of 7.4 months prior to beginning treatment.

Over 100 patients were examined with duplex scanning. In these patients, 17% of the ulcers were associated with incompetent perforator veins. Healing was achieved in 57% after 2 1/2 months. After four months, 75% of the ulcers were healed and after one year, 96% were healed. Healing was adversely affected by ulcer size and the presence of a diminished ankle brachial index. Superficial or perforator vein incompetence did not affect healing. Post healing, patients were treated with elastic compression stockings but compliance was not specified. Ulcer recurrence with life table analysis was 21% at 12 months, 29% at 24 months, and 38% at 36 months.

COMMENTARY

This study emphasizes that nonoperative treatment of venous ulceration with the use of compression therapy is effective in the healing of venous ulcers. These results are similar to those reported from our institution where 79% of 113 ulcers were healed at six months and 87% were healed by one year.1 A recent study from the Charing-Cross Hospital in London also reported that of 198 legs with venous ulceration treated with compression bandages, 74% were healed at six months.2 At the Medical College of Wisconsin, 85% of 97 venous ulcers were healed with compression therapy utilizing Unna boots.3 While it is clear that compression therapy can heal a large majority of venous ulcerations, recurrence is a major problem. In the current study, 29% of healed ulcers had recurred by two years. In our study,1 27% of healed ulcers recurred by two years.

The important question then is what can be done to decrease the recurrence rate of venous ulceration. It must be remembered that the target organ of venous insufficiency is not the veins but the skin. Patients with advanced lipodermatosclerosis and venous ulceration have significant abnormalities in cutaneous lymphatics and in cutaneous microarterial and venous circulations. Transcutaneous oxygen pressures at or near zero have been reported in areas of scarring associated with healed venous ulcers. Given the extent of cutaneous damage in the lipodermatosclerotic skin associated with venous ulceration, I believe it is unlikely that any form of therapy, currently available or conceivable, will eliminate recurrence of venous ulceration with 100% efficacy.

Today there is active discussion regarding the role of subfascial endoscopic perforator surgery (SEPS) in improving healing of venous ulceration and decreasing recurrence post healing. Sparks et al. reported no ulcer recurrence after SEPS but the average followup was only 8.6 months.4 Data from a large registry of patients undergoing SEPS is less encouraging.5 In that registry, 70% of 155 limbs had venous ulcers treated with SEPS. However, a total of 72% also had other venous adjunctive procedures performed concurrent with the SEPS procedure. At six months, 79% of ulcers were healed. This is not so different from the 79% in the Oregon study, 75% from the North Carolina study, and 74% from the Charing-Cross Hospital study, all using compression therapy without SEPS for treatment of venous ulceration. Recurrence rates at two years also did not appear different (27% Oregon, 29% North Carolina, and 28% SEPS registry).

What can be concluded from this analysis? First, it is clear that with assiduous attention to detail, compression therapy can heal a large majority of venous ulcers. Secondly, no current therapy, operative or compressive, can heal all venous ulcers. Thirdly, no matter what form of therapy is used, recurrence of venous ulceration remains a problem. At this time, without further data, we cannot state conclusively that operative therapy is or is not indicated in the treatment of venous ulceration.

Physicians relying primarily on compression therapy for treatment of venous ulcer can be assured that they are providing highly effective treatment. Recurrence, however, is to be expected in a significant minority of patients. Existing data do not provide a mandate to perform subfascial endoscopic perforator surgery in patients with venous ulceration. As noted above, based on the SEPS registry, healing rates and recurrence rates do not appear substantially different than that achieved with compression alone.

It is my sincere hope that one day a treatment will compliment compression therapy in the treatment of venous ulcers. Advocates of invasive treatment are to be congratulated for demonstrating that these procedures can be performed and performed safely. While it takes courage and innovation to pioneer new surgical procedures, they must also be right. Given the present genuine equipoise regarding operative procedures for venous ulcer, papers such as this one should help to further prod the surgical advocates into producing the sorely needed data which would prove the benefits for their procedures. vdmon068

REFERENCES

1. Mayberry JC, Moneta GL, Taylor LM Jr, Porter JM. Fifteen-year results of ambulatory compression therapy for chronic venous ulcers. Surgery 1991; 109:575-81.

2. Guest M, Smith JJ, Sira MS et al. Venous ulcer healing by four-layer compression bandaging is not influenced by the pattern of venous incompetence. Br J Surg 1999; 86:1437-40.

3. Erickson CA, Lanza DJ, Karp DL et al. Healing of venous ulcers in an ambulatory care program: The roles of chronic venous insufficiency and patient compliance. J Vasc Surg 1995; 22:629-36.

4. Sparks S, Ballard JL, Murray JS, Bergan JJ. Early benefits of subfascial endoscopic perforator surgery (SEPS) in healing of venous ulcers. Ann Vasc Surg 1997; 11:367-73.

5. Gloviczki P, Bergan JJ, Rhodes JM, Canton LG, Harmsen S, Listup DM, and the North American Study Group. Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: Lessons learned from the North American Subfascial Endoscopic Perforator Surgery (NA-SEPS) Registry. J Vasc Surg 1999; 29:489-502.






Manual of Sclerotherapy
Author: Neil S. Sadick, MD
Lippincott Williams & Wilkins, Philadelphia
 Year: 2000 Pages: 200

REVIEW BY:
John J. Bergan, MD, FACS
La Jolla, California

While there is a resurgence of interest in treating venous disorders by general and vascular surgeons, there has been little interest in sclerotherapy. Yet, sclerotherapy is inextricably linked to surgical care of primary venous insufficiency.

This volume, from an experienced sclerotherapist in private practice in the demanding atmosphere of Manhattan, nicely complements the scholarly and voluminous tome on sclerotherapy by Mitchel Goldman, MD. Sadick has digested sclerotherapy down to its essences. The chapters are full of lists of terminology, risk factors, drug therapy, equipment needs, ultrasound findings, and even checklists to make sure that all of the pretreatment diagnostic consents and a variety of treatment considerations have been addressed. Sadick is nothing if not complete about every detail.

The book's outline follows a predictable course with an introduction to the anatomy, physiology, and epidemiology of primary venous insufficiency. After addressing the in-office history, physical examination, and ultrasound testing, Sadick provides the nuts and bolts of setting up a sclerotherapy suite, what documentation is necessary, and which sclerosing agent to use. He then goes into detail regarding treatment of telangiectasias, then reticular varicosities, and finally varicose veins and the problems of saphenous reflux.

It is refreshing to see a chapter on when to ask for surgical consultation. As experience is gained in sclerotherapy, the inevitable questions arise about post treatment compression, how to minimize complications, and what is next on the horizon. All of these are covered in detail and in a succinct fashion which makes the book a quick read.

There is a profusion of color photographs interspersed with the tables and black-and-white and color diagrams. It is hard to imagine that any question is left unanswered in this text.

I would have welcomed Dr. Sadick's explicit point of view on a number of controversial topics. For example, principles of injection of the saphenofemoral and saphenopopliteal junctions are given but we do not have the author's opinion about whether this should be done at all; or if done, what precautions to use to avoid massive tissue necrosis caused by concentrated sclerotherapeutic injections. We know Sadick to be an expert in the use of laser and noncoherent pulsed light sources but what does he think about treating lower extremity blemishes? Many others have quietly relegated the laser to lesions above cardiac level. Fortunately, there is a hint of the author's opinion when he gives four major reasons why consistent results have not been achieved in treatment of leg veins by light sources.

Sadick has barely been able to include a few words on cryosurgery and endovenous shrinkage by radiofrequency heating so these remain tantalizing and attractive possibilities for the future.

This is much to recommend about this Manual of Sclerotherapy . One would hope that vascular surgeons, especially those in leadership positions, would include instruction in sclerotherapy in their programs of vascular surgery education. Although the manifestations of severe chronic venous insufficiency are expressed in the skin, vascular surgeons should not abandon entirely the treatment of venous insufficiency to our colleagues in dermatology. review




ACCEPTANCE OF DIFFERENT TREATMENT MODALITIES IN PHLEBOLOGY (Akzeptanz Verschiedener Therapieformen in der Phlebologie)
 Kl?ken H, Voiss P, Gallenkemper G, H?lle T, Rabe E
Phlebologie 1999; 28:169-74

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

Patient compliance plays an important role in the success of treatment of chronic venous insufficiency (CVI), especially with regard to compression therapy. The objective of this multicenter patient survey was to assess a patient's evaluation of different treatment modalities.

At the end of a session of treatment, questionnaires were given to all phlebologic patients of the participating institutions in the multicenter study. Therefore, this is a retrospective study, and participation was voluntary. Only patients without generally deteriorating disease and without other circulatory or neurologic disease in the legs were included.

A total of 235 questionnaires (170 female, 65 male) (mean age 55 13.04) were analyzed. The questionnaire allowed patients to assess expectation as well as satisfaction with treatment of the different manifestations of CVI with a score from 0 to 4. The investigators graded CVI into five stages of severity according to the modified European Widmer grading system. This system is: 
  0  Venous pathology without CVI

  I  Corona phlebectatica and edema of the ankle

 II  In addition, hyperpigmentation or depigmentation,
     lipodermatosclerosis, atrophie blanche

IIIa Healed ulcer

IIIb Actual ulcer
The results were as follows: 1) Expectancy increased with the severity of the CVI. Patients with CVI grade IIIb (actual ulcer) expected the most and were the most motivated for treatment. 2) Overall satisfaction in each case was above average on the scale from 0 to 4. 3) Compression yielded best satisfaction followed by medication, operation, and sclerotherapy. 4) Best improvement, however, was achieved by operation followed by compression, sclerotherapy, and medication. 5) The least success was expected and felt to occur in grade IIIa CVI (healed ulcer). 6) Compression therapy was well tolerated by patients with CVI.

The expected results were not reached completely in any manifestation of CVI in any grade (cosmetic, pain, swelling, heaviness, bursting sensation, cramps, other disagreeable sensation, ulcer, working capacity, healing). The best expectancy/satisfaction relationship was observed first with compression, next with operation, and last with sclerotherapy.

When asked whether they would have treatment done again in the same situation, patients answered 95% yes for compression, 89% yes for medication, 84% yes for operation, and 68% yes for sclerotherapy. The reason medication ranks high seems to be due to the fact that it is agreeable and noninvasive.

COMMENTARY

This article reveals nothing unexpected; however, in this era of evidence-based medicine, such surveys are worthwhile. At the same time, they are an eye-opener in spite of the relatively soft data on which they are based.

One of the most revealing questions is whether patients would have the same therapy again. We have done similar surveys and found the same figures for operation. Patients tend to be kind to the investigating institution as they may be treated there again. Therefore, it is wise to subtract a bit from the noted satisfaction.

This article contains data from the thesis written by one of the authors (H. Kl?ken). Another article which I recommend for reading is How Successful is Varicose Vein Surgery? A Patient Outcome Study Following Varicose Vein Surgery Using the SF-36 Health Assessment Questionnaire . (Baker DM, Turnbull NB, Pearson JCG, Makin GS. Eur J Vasc Endovasc Surg 1995; 9:299-304). vdfis068




CONTRIBUTORS TO VENOUS DIGEST 1999

The success of the Venous Digest during 1999 is largely due to the excellent abstracts and commentary prepared by the following individuals. A glance at the list will show that these are truly a "Who's Who" of physicians interested in venous disease. The Venous Digest is enormously grateful to them for their of good work during 1999.

John J. Bergan, MD, Editor

1999 Contributors

Ali F. AbuRahma, M.D., Charleston, West Virginia
Gy?rgy Acsady, MD, Budapest, Hungary
Prof. Claudio Allegra, Rome, Italy
Enrico Ascher, MD, Brooklyn, New York

Jeffrey Ballard, MD, Loma Linda, California
Manuela Birrer, MD, Berne, Switzerland
Richard Blackwell, MD, Birmingham, Alabama
John Blebea, MD, Hershey, Pennsylvania
Paul H. S. Bloch, MD, Norfolk, Virginia
Henri Boccalon, MD, Toulouse, France
Andrew Bradbury, MB, Edinburgh, Scotland

Attilio Cavezzi, MD, San Benedetto, Italy
Peter Charlesworth, FRACS, Auckland, New Zealand
Peter Conrad, FRCS, Penrith, Australia
Paul R. Cordts, MD, Tripler AFB, Hawaii
Andr? Cornu-Thenard, MD, Paris, France

Ralph DePalma, MD, Reno, Nevada
Panos Dimakakos, MD, Athens, Greece
Csaba Dzsinich, MD, Budapest, Hungary

David Easter, MD, San Diego, California
Bo Eklof, MD, Honolulu, Hawaii
Ermenegildo Enrici, MD, Buenos Aires, Argentina

Vicki Fahey, RN, MSN, Chicago, Illinois
Dr. med. Reinhard Fischer, Wattwil, Switzerland
Prof. Michael F?ldi, R??lehofweg, Germany
Julie Freischlag, MD, Los Angeles, California

Prof. Ricardo Gesto, Madrid, Spain
Mitchel Goldman, MD, La Jolla, California
David Green, MD, Bethesda, Maryland

J. P. Henriet, MD, Illkirch, France
Anil Hingorani, MD, Brooklyn, New York
John T. Hobbs, MD, Gent, Belgium

Mark Iafrati, MD, Andrews AFB, Maryland

Georges Jantet, MD, Paris, France

Lois Killewich, MD, Galveston, Texas
Prof. Renate Koppensteiner, Z?rich, Switzerland
Prof. Mehmet Kurtoglu, Istanbul, Turkey

Nicos Labropoulos, MD, Maywood, Illinois
Stephen Lalka, MD, Indianapolis, Indiana
Prof. Dr. med. H.-J Leu, Novaggio, Switzerland

Prof. F. Mahler, Berne, Switzerland
Dr. med. h.c.K. Me?mer, M?nchen, Germany

H.A.M. Neumann, MD, Maastrict, Netherlands
Prof. Lars Norgren, Lund, Sweden

Frank Padberg, MD, East Orange, New Jersey
Prof. Hugo Partsch, Wien, Austria
Michel Perrin, MD, Lyon, France

Neil Sadick, MD, New York, New York
Clifford Sales, MD, Westfield, New Jersey
John H. Scurr, FRCS, London, England
Prof. Jan Struckmann, Copenhagen, Denmark
Prof. Mieczyslaw Szotstek, Warszawa, Poland

Marianne Vandendriessche, MD, Gent, Belgium
J. Leonel Villavicencio, MD, Bethesda, Maryland

Thomas Wakefield, MD, Ann Arbor, Michigan
Robert Weiss, MD, Hunt Valley, Maryland
Harold Welch, MD, Burlington, Massachusetts
Jock Wheeler, MD, Norfolk, Virginia
Matthias Widmer, MD, Berne, Switzerland




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