TREATMENT OF TELANGIECTASIAS BY PHOTODERM VL AND SCLEROPLUS-LASER
 Nu? B, Brodersen J, Kapp A
Phlebologie 1999; 28:149-52

COMMENTARY BY:
PD Dr. med. Eberhard Rabe
President, German Society of Phlebology
Bonn, Germany

The authors performed a prospective, comparative study on the results of leg telangiectasias in ten patients (30 to 59 years). Treatment of telangiectasias was performed by flashlamp-pumped, pulsed-dye laser (ScleroPLUS) and an intense pulsed light source (PhotoDerm VL) in the same patient in different leg regions. Neither method caused significant improvement of dermatological symptoms in most of the patients. The therapeutic effect of using the light source was slightly better than using the laser but more serious side effects were observed.

After a single treatment, a good result was seen in two cases with the light source and in one case with the laser. A moderate improvement was demonstrated in two patients of each group. No improvement was seen in four cases with the laser and in six cases with the light source. In two patients, the lesions were worsened after light source treatment and in one patient after laser care.

COMMENTARY

The role of lasers and light sources in treating lower extremity telangiectasias is widely debated in the literature. In this small series, the authors could show no significant improvement of dermatological symptoms in most patients treated with either the intense pulsed light source or the flashlamp-pumped, pulsed-dye laser. They recommended compression sclerotherapy as the gold standard in the therapy of leg telangiectasias.

This corresponds well with published reports where the treatment of lower extremity blood vessels with laser and light source has not been as successful as the treatment of facial telangiectasias. In a recent publication, Dover et al.1 reviewed the role of laser and light source in treatment of leg veins. They stated that because of the relatively modest results demonstrated with laser and light source, the high rate of success and the relatively low costs of ambulatory phlebectomy, compression sclerotherapy and superficial sclerotherapy, they generally recommend the use of laser and light source only for vessels that remain after these treatments are completed.

In leg telangiectasias, lasers and light sources should be considered as an alternative approach in patients who do not tolerate sclerotherapy, those who do not respond, those who are fearful of needles, and those who have telangiectatic matting after treatment.

At this time, more randomized, controlled, comparative studies are necessary to define the role of different laser systems in phlebology. ivdfrab2

REFERENCE

1. Dover JS, Sadick NS, Goldman MP. The role of lasers and light sources in the treatment of leg veins. Dermatol Surg 1999; 25:328-35.







PERCUTANEOUS THERAPY OF PERIPHERAL VASCULAR MALFORMATIONS
Gomez EG, Carreira Villamor JM, Perez RR et al.
Rev Clin Exp 1998; 198:565-70

COMMENTARY BY:
Dr. Ermenegildo A. Enrici
Dr. Cristobal Papendieck
Argentine Catholic University
Buenos Aires, Argentina

The authors describe their experience in treatment of peripheral vascular malformation by selective embolization in 35 patients from 1993 through 1997. According to the Mulliken classification, 45% had high-flow vascular malformations (hemodynamically active, HAVM) and 54.3% had low-flow vascular malformations (hemodynamically inactive, HIVM). Diagnostic methods used were the same for both groups: Clinical, radiological, duplex, and MRI. Direct-puncture angiography was used as a complement for HIVM and selective arteriography for HAVM. This was done in order to assess the anatomy and the number of arterial flow vessels and venous outflow vessels as well as the lesion itself.

In most cases, embolization was performed with Ethibloc although Gelfoam, Histoacryl, and Gianturco coils were also used. A total of 126 embolizations were done (average of 3.6 per patient). Two patients sustained severe complications with cutaneous necrosis and extrusion of the embolization material. All patients improved objectively and subjectively except for the patient with the most extensive necrosis. The authors conclude that percutaneous embolization alone or in combination with surgery should be the initial and probably only treatment for the management of vascular malformations.

COMMENTARY

This study, performed at a very experienced institution, is extremely valuable. Hemangiomas (which can be considered simply as tumors and not malformations) are often excluded from classification of vascular malformations. They are a type of angioma that tend to involute over time although they may also persist into adult life. This diverse behavior is undoubtedly due to the extremely variable histologic features. Phlebangiomas (with contained phleboliths) are mainly a type of HIVM but may be potentially active (HAVM). Consequently, we consider the approach raised by the authors to be interesting as they classify these as active and inactive vascular malformations. These are synonyms for macro- and microarteriovenous fistulae which creates two manifestations with equal treatment by different approaches.

Accurate classification is relevant to a standardization of treatment. Useful nomenclature should classify a pathology according to its histologic architecture, functional behavior, and localization. A small ocular hemangioma can cause blindness, a cerebral venous aneurysm can cause severe functional impairment, and a cirsoid aneurysm may require disarticulation or major amputation at a maxillary, frontal, or mid-femoral level. Undoubtedly, the therapeutic approach advocated by the authors in their cases is appropriate. Generally, however, the diagnostic plan has been internationally standardized. In the high- or low-flow vascular malformation classification, the anatomic localization is mandatory; i.e., face, fingers, genitalia are not the equal to thigh, gluteus or shoulder.

In general, any embolization or surgical intervention involving terminal pedicles is critical. In pediatrics, embolization with alcohol and its byproducts (and especially acrylates) is not free of regional and/or systemic risks. Therefore, embolotherapy should be restricted to experienced centers such as the case in the current report.

We would have been interested in knowing the clinical and/or histological definition of each vascular malformation in order to determine that different procedures such as specific drugs, surgery, or chronotherapy did not achieve the same results. We note that metallic coil embolizations were not considered as an alternative in this study. ivfdenr1







EFFECT OF COMPRESSION STOCKINGS ON LEG VOLUME IN PATIENTS WITH VARICOSE VEINS
M?ller-B?hl U, Beim B, Fischbach U, Windeler J, Finkenst?dt Th, Schl?fer M
Phlebology 1998; 13:102-06

COMMENTARY BY:
Prof. Ricardo Gesto
Madrid, Spain

The authors present a study of 46 patients with varicose veins of the greater saphenous vein network in order to test a new volumeter and to verify the effect of compression stockings on the volume of the affected limbs. The chief objective was to quantify venous blood volume in the leg in the supine and upright positions using a new imaging system for plethysmographic measurement (Perometer). This instrument allows very precise, reliable and repeatable measurements of volume. In addition, the authors wished to assess the effect of acute and long-term compression with thigh-length compression stockings on volume in legs with varicose veins compared with normals.

A total of 46 patients with unilateral varicose veins due to greater saphenous vein incompetence were selected. All had morphologically and functionally normal deep venous systems and had not used elastic hose or bandages for at least one week. The contralateral limb was free of varicose veins and showed no sign of deep vein pathology. Exclusion criteria included clinical evidence of lymphatic insufficiency, uncompensated kidney or cardiac failure, phlebitis or acute deep vein thrombosis, leg ulcers, and diuretic/venotonic medications. All patients underwent a duplex examination to exclude deep vein disorders and to identify varicose veins and incompetent perforating veins. The severity of the venous disorder was catalogued according to the CEAP classification. The normal leg was used as a control reference. All patients were examined in supine and upright positions.

The Perometer produces a full-scale drawing of the limbs as light rays are simultaneously focused on, and reflected from, the side and from the front as the device moves along the entire length of the limb. The measurement can be made in supine and upright positions. In this study, measurement was done in both positions at 8 o'clock each morning. A volumetric measurement was then done after application of the thigh-length, medium-compression hosiery. The measurements were repeated eight hours later and on the morning of the seventh day after the start of the study. The differences were analyzed with a paired t-test. Values of p < 0.05 were considered significant.

Leg volume was greater in the upright position than in the supine position and averaged 255.5 ml for normal legs (p < 0.001) and 236.5 ml in legs with varicose veins (p < 0.001). Most of the extra volume was located in the thigh. The difference in volume between the normal leg and the leg with varicose veins was, on average, 172.5 ml in the supine position and 187 ml when standing. Most of the extra volume was in the calves. The use of compression stockings led to mean reductions of 314 ml in the volume of normal legs and 358 ml in legs with varicose veins. In the standing position, mean volume reduction was 349.5 ml and 394 ml (p < 0.001), respectively.

The volume reduction compared with total volume was greater in the thigh. Compression for eight-hour periods did not lead to additional changes in the volume of either leg. Calf volume of legs with varicose veins was more reduced than in normal limbs due to the transfer of blood from the veins of the calf into the thigh. Compression during a seven-day period did not cause any additional change in the volume of the normal leg. However, there was a reduction in leg volume in legs with varicose veins (-62 ml supine position, -72 ml standing position). The reduction was greater in the calves. There was still a difference in volume between the two groups but after day 7, the difference was very little.

COMMENTARY

The new opto-electronic method for volumetric measurement seems to be reliable. I would have liked more information on the apparatus such as ease of examination, length of examination, comfort level for patient and physician, and cost. These parameters would allow practitioners to compare this method to the currently available techniques.

The results of the study coincide with what might be expected from the pathophysiology of the process with the advantage that the volume decrease could be quantified in milliliters. It is obvious that the volume of a leg with varicose veins is determined by the capacity of the veins themselves as well as interstitial swelling. Therefore, the volume of blood is reduced with changes in posture and elastic compression. As was shown, the volume due to increase in interstitial fluid took longer to reduce and might even fail to reduce if tissue damage was irreversible.

From this study, explained in quantitative terms, it is deduced that use of compression stockings immediately reduces volume in legs with varicose veins due to displacement of blood. The lesser reduction in volume after seven days is due to resorption of the edema and interstitial fluid. ivdfges2







THE EFFECT OF GRADED COMPRESSION ELASTIC STOCKINGS ON THE LOWER LEG VENOUS SYSTEM DURING DAILY ACTIVITY
 Buhs CL, Bendick PJ, Glover JL
J Vasc Surg 1999; 30:830-35

COMMENTARY BY:
Prof. Massimo D'Addato
Bologna, Italy

In this study, the effect of wearing elastic stockings during regular daily activities was tested in a group of female volunteers.

A total of 21 volunteers were recruited from an outpatient surgery setting. Their work required them to be on their feet most of the day. They were examined on two separate days. On one day, they wore no support stockings; on the other day, they wore 20 to 30 mmHg stockings. Calf circumference, diameter of the posterior, peroneal, and greater saphenous veins, and the number of perforators were measured in each volunteer twice on each day of the study, once at baseline early in the morning and once after the daily activity. The majority of subjects (17/21, 81%) did not have any overt venous disease and were considered class 0 according to the CEAP clinical classification proposed by the International Consensus Committee on Chronic Venous Disease.

Calf circumference significantly increased after daily activity when stockings were not worn (+2.4 1.0 cm, p < 0.001) and significantly decreased when stockings were worn (-0.5 0.7 cm, p = 000.3). The wearing of stockings also caused a significant difference in the diameter of all venous segments when compared to the same vessels when stockings were not worn (p = 0.001). The number of visible perforators increased significantly with a significant increase in caliber after daily activities with no stockings. These did not change significantly (with significant decrease in caliber) after activity with stockings. Subjective feeling of swelling and aching was significantly decreased after the period if stockings were worn.

COMMENTARY

This study shows again the anatomical changes in the venous system of healthy subjects as altered by the use of support elastic stockings. Although no hemodynamic data are provided, several other reports fulfill this need. Very little anatomical data on the effect of elastic stockings was available in the literature until recently. While the data presented are not surprising and may reflect our collective intuition, it is important to have scientific proof of our prejudice. There will probably be no impact of this study on daily practice but the data presented will help with further studies on venous hemodynamics both in the healthy subject and with venous patients. ivdfdad1







INVESTIGATION OF THE MECHANISM OF LYMPHOCYTE INJECTION THERAPY IN TREATMENT OF LYMPHEDEMA WITH SPECIAL EMPHASIS ON THE CELL ADHESION MOLECULE (L-SELECTIN)
 Ogawa Y, Yoshizumi M, Kitagawa T, Katoh I, Hisaeda H, Himeno K
Lymphology 1999; 32:151-56

ABSTRACT AND COMMENTARY BY:
Prof. Micha?l F?ldi
Fachklinik f?r Lymphologie
R??lehofweg, Germany

In 1984, Katoh published a paper about treatment of lymphedema of the limbs by injection of autologous lymphocytes into the principal artery of an affected extremity.1 In some cases, swelling decreased rapidly but the effectiveness was short-lived. Now, six years later, the authors state, "Repeated therapies in combination with other conservative treatments are necessary to maintain continuous relief from the edema.2

In the present article, the authors describe their actual protocol and the results obtained in a total of 46 patients, 33 with lymphedema of the lower extremities and 13 with lymphedema of the upper extremities. From venous blood drawn from an antecubital vein, lymphocytes were isolated using a Baxter CS-3000 blood cell extractor. Promptly after separation, a 100 ml bolus injection was given into a proximal artery of the affected limb. The intraarterial injections were repeated "at least four times every one or two weeks. Other treatments of arm lymphedema included massage, use of bandages, and oral benzopyrones."

Treatment results were estimated by calculating an edema reduction ratio, accomplished by measuring the circumference of the most swollen site of the affected limb and that of the corresponding site on the contralateral limb. This was done on the day of admission and again on the day of discharge. The authors report marked improvement which persisted from "several weeks to greater than five years."

COMMENTARY

This paper has several shortcomings. "Other treatments" are not specified (what kind of massage, which of the many benzopyrones, in what dose). A control group was not studied. A control group was necessary to evaluate the results of the other treatments applied alone without the injection of lymphocytes.

In Table 1, only the results of compression therapy combined with intraarterial injection are summarized. Massage and benzopyrones are not mentioned. Importantly, the authors did not mention in what stage of disease their patients presented or whether fibrosclerotic alteration, if present, was influenced by the treatment. Under their heading "Technique for Intraarterial Lymphocyte Injection," the authors describe only treatment of arm lymphedema. There is no mention of leg lymphedema. If measurements were performed only at admission and on discharge, how can it be stated that the improvement lasted greater than five years in some cases? Finally, in order to assess effectiveness of lymphedema treatment, volume measurements must be performed. Measurement of circumference is inadequate.

I must call attention to the fact that repeated injections into the brachial or femoral artery are invasive procedures. The authors, who are admittedly skilled surgeons, report that they encountered no "notable" complications. However, I am skeptical that even the most skilled surgeon can repeatedly puncture these arteries in a limb with elephantiasis without exposing it to danger. Therefore, it is no wonder that in 16 years no other author has repeated the treatment advocated by Katoh et al.

On the other hand, the molecular biological findings of the authors; i.e., the increased expression of L-selectin in the lymphocytes and that only the injection of lymphocytes influences lymphedema and that monocytes remain without effect, are of scientific interest and merit further study. ivdffol3

REFERENCES

1. Katoh I, Harada K, Tsuda Y, et al. Intraarterial lymphocyte injection for treatment of lymphedema. Jpn J Surg 1984; 14:331-334.

2. Katoh I, Egawa Y, Kitagawa T, et al. Intraarterial lymphocyte injection for lymphedema of the extremities. In: Nishi M, Uchida S, Yabuki S (eds). Progress in Lymphology XII. Excerpta Medica, Amsterdam, The Netherlands, 1990; pp 81-84.







PROSPECTIVE STUDY OF SAFETY, PATIENT SATISFACTION, AND LEG ULCER HEALING FOLLOWING SAPHENOUS AND SUBFASCIAL ENDOSCOPIC PERFORATOR SURGERY
Nelz?n O.
Br J Surg 2000; 87:86-91

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

Subfascial endoscopic perforator surgery (SEPS) is being widely performed. However, controversy remains over the role of perforating veins in the development of skin changes and venous ulceration.

This study was conducted between March 1993 and June 1997. The 46 patients operated on before 1995 did not undergo duplex ultrasound imaging. Patients were classified according to the CEAP classification system and only those considered class 3 or worse were considered for SEPS. Assessment was retrospective following the introduction of the classification system (the Widmer classification system was previously used).

A standard SEPS procedure was performed but this was, in part, combined with surgery to superficial veins. Of the total 149 procedures, only one was aborted. No serious complications were noted although some patients complained of pain. A total of 30/36 ulcers healed with more than half healing within one month. Three patients experienced recurrence.

Discussing the results, the authors reference previous reports, including retrospective studies. They acknowledge that controversy remains regarding both the role of incompetent perforating veins and whether or not patients without skin changes should undergo the procedure. They discuss morbidity associated with SEPS, including delayed healing and infection rate.

Again difficult to interpret is the combination of SEPS with saphenous vein surgery. Again reinforced is the importance of a careful preoperative assessment to identify patients with deep and superficial venous insufficiency can be made. When combining SEPS with other forms of surgery, one cannot assess accurately the contribution of each procedure. However, this study supports previous studies that SEPS is safe, effective, and associated with venous leg ulcer healing.







EFFECTIVENESS OF MESOGLYCAN TOPICAL TREATMENT OF LEG ULCERS IN SUBJECTS OF CHRONIC VENOUS INSUFFICIENCY
La Marca G, Pumilla G, Martino A
Minerva Cardioangiol 1999; 47:315-19

COMMENTARY BY:
Prof. Massimo D'Addato
Bologna, Italy

This study focuses on topical treatment of venous leg ulcers, an issue widely discussed in the literature and still unresolved.

The authors studied a series of 40 patients with venous ulcers of the lower limbs measuring 1 to 78 cm2. They were categorized into two randomized groups for local medical treatment. All were treated with elastic bandaging and daily medications with either vegetal stimulins or mesoglycan. After 15 days of treatment, the mean ulcer dimension was reduced 35% in the mesoglycan group and 26% in the stimulins group. At the end of the two-month study period, the healing rate was 95% in the mesoglycan group and 80% in the stimulins group. From these data, the authors believe that mesoglycan is efficacious and suggest further study on its mechanism of action.

COMMENTARY

This study has several problems in study design and in presentation of data. No details are given on the kind of venous disease present, the etiology of the venous insufficiency, possible treatment prior to enrollment in the study, or the presence of a newly formed ulcer versus a recurrent ulcer. Surprisingly, no hemodynamic details are given in the description of the clinical cases. The randomization method is not described. The statistical method used is not given; therefore, it is difficult to understand the significance of the results. The mechanism of action of mesoglycan is unclear and this study does not add any insight on this. While other aspects of the article need wide discussion as well, the above points are sufficient to cloud the study and its conclusions.

Treatment of venous ulcers is exceptionally complex and not close to being solved. While there are universally accepted fundamentals (elastic compression, treatment of underlying venous disease, adequate wound treatment), no definitive answers have been reached on the type of topical treatment or on the prevention of recurrences. I do not believe that this study brings us any closer to the final conclusion. ivdfdad3




HIGH PLASMA CONCENTRATION OF FACTOR VIIIc IS A MAJOR RISK FACTOR FOR VENOUS THROMBOEMBOLISM
 Kraaijenhagen RA, In't Anker PS, Koopman MMW, Reistma PH, Prins MH, van den Ende A, B?ller HR.
Thromb Haemost 2000; 83:5-9

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

Various thrombophilic factors are continuously being reported. A recent suggestion has been elevated levels of factor VIIIc. The aim of this study from the Department of Vascular Medicine in Amsterdam was to assess the relevance of the factor VIIIc plasma concentration in patients with venous thromboembolism.

There were 65 patients with a single episode of venous thromboembolism and 60 matched patients with recurrent thromboembolism. There were 60 age- and sex-matched controls with suspected venous thromboembolism but no verification of the diagnosis. To minimize the influence of the acute phase, blood samples for analysis were taken at least six months after the acute thromboembolic event. In a subset of 28 patients, factor VIIIc was determined several years after the first measurement. In addition, a family study was done. In the control group, the single-episode group, and in the recurrent-episode group, the frequency of plasma levels of factor VIIIc above 175 IU/dl (90th percentile of controls) were 10, 19 and 33%, respectively. For each 10 IU/dl increment of factor VIIIc, the risk for a single and recurrent episode of venous thromboembolism increased by 10 and 25% respectively. The repeated plasma levels analyzed in the subset of patients were consistent over time. The family study indicated a high incidence of elevated factor VIIIc plasma levels among first-degree family members. Adjustment for fibrinogen, C-reactive protein, and known thrombophilic risk factors did not change the observed association of elevated factor VIIIc with thromboembolism. The authors conclude that elevated factor VIIIc levels are a significant, prevalent and dose-dependent risk factor for venous thromboembolism predisposing to recurrent venous thromboembolism.

COMMENTARY

In the investigation of consecutive patients with venous thromboembolism, there is always a group without obvious risk factors or explanation for the development of the disease (idiopathic or cryptogenic thrombosis). With increasing knowledge and especially with identification of molecular defects within the hemostatic system, this group continues to decrease.

Not too long ago, we knew little about factor V Leiden and the prothrombin mutation. In this paper, the Amsterdam group analyzed an additional factor, elevation of factor VIII procoagulant activity. The interesting observations are the high frequency of elevated plasma levels in patients with venous thromboembolism especially in those with recurrences, and a seeming increased risk for venous thromboembolism with increased levels, indicating a dose-response relation. There also seems to be a genetic possibility for the increased levels although this is suggested on the basis of just one family. The authors correctly identify the need for more extensive family investigations to order to establish the role of a genetic influence. This is certainly an interesting and challenging aim for future research activities.

A question raised in recent years is how various thrombophilic factors add to the risk of thrombosis, a problem not at all analyzed or even discussed in the present study. This would certainly have been possible and an analysis of synergism would have added considerably to the value of the paper.

Although various precautions have been taken, there is one caveat worth mention. All samples were taken in patients who had already sustained a thromboembolic event. To more reliably evaluate the risk for development of venous thromboembolism in patients with high levels, a study following the population prospectively with different levels of factor VIIIc needs to be done.




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


Fate of Human Femoral Vein Valve Competency after Cryopreservation
Villemur B, Giardulli I, Sessa C et al.
J Mal Vasc 1999 24:126-31

Although this is a preliminary study, the authors conclude that the method of preservation must be improved in order to preserve vein valve competency. Histologic findings suggest that elastic fibers play a major role in failure of vein competency during cryopreservation.


The Expression of Adhesion Molecules ICAM-1, VCAM-1, LFA-1 and VLA-4 in the Skin is Modulated in Progressing Stages of Chronic Venous Insufficiency
Peschen M, Lahaye T, Hennig B, et al.
Acta Derm Venereol (Stockh) 1999; 79:27-32

The findings in this research study suggest that following an initial peak expression of adhesion molecules, the effect is not down-modulated but remains upregulated. This fact may promote the tissue damage by an upregulated influx of activated leukocytes which finally leads to skin ulceration.