The natural history of calf vein thrombosis: lysis of thrombi and development of reflux

PURPOSE: Although the fact is well accepted that deep venous thrombosis (DVT) of the iliac, femoral, and popliteal veins can lead to the post-thrombotic (postphlebitic) syndrome, the significance of isolated calf DVT on the development of late venous sequelae and physiologic calf dysfunction is unknown. The purpose of this study was to review the outcome of 58 limbs with isolated calf DVT and report the clinical, physiologic, and imaging results up to 6 years after the onset of DVT. METHODS: The study consisted of 58 limbs of 54 patients in whom isolated calf vein DVT was diagnosed between 1990 and 1995. Proximal propagation of clot, lysis of thrombi, and development of symptomatic pulmonary emboli were examined. Of the patients, 28 received anticoagulation therapy, and 26 did not, but they had follow-up with serial duplex scans. At late follow-up 1 to 6 years later (median, 3 years), 23 patients were examined for the post-thrombotic syndrome, and all 23 underwent clinical examination, color-flow duplex scanning, and air plethysmography. RESULTS: Proximal propagation of DVT from the calf veins into the popliteal or thigh veins occurred in 2 of 49 cases (4%) within 2 weeks of diagnosis. No patient had clinically overt pulmonary emboli develop regardless of whether anticoagulation therapy was received or not. The most common site for calf DVT was the peroneal vein (71%). Complete lysis of calf thrombi was found in 88% of the cases by 3 months. At 3 years, 95% of the patients were either asymptomatic or mildly symptomatic, and 5% had discoloration of the limb. No ulcers occurred. By air plethysmography, physiologic abnormalities were found in 27% of the cases, which was not significantly different from normal controls. Valvular reflux by duplex scanning of the calf vein segment with DVT was found in 2 of 23 cases (9%). However, reflux in at least one venous segment not involved with DVT was found in 7 of 23 cases (30%), which was higher than, but not statistically different from, normal controls, with reflux occurring in 5 of 26 cases (19%). CONCLUSIONS: Isolated calf vein DVT leads to few early complications (ie, clot propagation, pulmonary emboli) and few adverse sequelae at 3 years. The peroneal vein is most commonly involved and should be a part of the routine screening for DVT. Lysis of clot usually occurs by 3 months. Although valvular reflux rarely is found in the affected calf vein at 3 years, reflux may be found in adjacent uninvolved veins in approximately 30% of the cases. The question of whether this will lead to future sequelae, such as ulceration, will require longer follow-up.     

In vivo effects of activated H-ras oncogene expressed in the liver and in urogenital tissues

PURPOSE: The clinical significance of isolated calf vein thrombosis (CVT), particularly with respect to development of the postthrombotic syndrome, remains controversial. The purpose of this study was to define the early natural history of CVT in relation to persistent lower extremity symptoms, propagation, recanalization, and the development of valvular incompetence. METHODS: Over a 116-month period, 499 patients with acute deep venous thrombosis (DVT) were referred to our research laboratory, of whom 58 (12%) had thrombosis confined to the calf veins of at least one extremity. The lower extremities of 268 patients (29 with isolated CVT) were followed-up clinically and with duplex ultrasonography at intervals of 1 day, 7 days, 1 month, every 3 months for the first year, and yearly thereafter. RESULTS: Seventy percent of extremities with CVT were symptomatic at presentation. Although the prevalence of clinical signs and symptoms decreased to 29% by 1 month, 23% of patients had persistent pain, edema, or both at 12 months. In contrast, 9% of uninvolved extremities contralateral to a CVT and 54% of extremities with proximal DVT remained symptomatic at 1 year (p = 0.004). Recanalization proceeded rapidly such that the mean thrombus load was reduced by 50% at 1 month and to zero at 1 year. The prevalence of valvular incompetence progressively increased such that reflux was present in 24% of extremities at 1 year. Although its investigation was not a primary goal of this study, pulmonary embolism was diagnosed at presentation and during follow-up in 11% and 3% of patients, respectively. CONCLUSIONS: The natural history of CVT is complicated by persistent symptoms and the development of valvular incompetence in approximately one-quarter of patients. This potential for persistent lower extremity symptoms should be considered in evaluating the clinical relevance of isolated calf vein DVT.     

Screening for major deep vein thrombosis in seriously injured patients: a prospective study

The purpose of the study is to determine the prevalence of acute deep venous thrombosis (DVT) in severely injured trauma patients, to investigate the cost effectiveness of a noninvasive surveillance program, and to assess the merit of current methods of prophylaxis against DVT. One hundred and forty-eight patients (295 limbs) with a mean age of 36.5 years, mean trauma score of 13.3, mean injury severity score of 22.4 with predominantly blunt injuries (88.5%), were part of the study. The mean length of stay was 17.6 days. Venous duplex scans (VDS) were performed on inpatients on days 2-5, day 11, and day 30 following admission. Sequential compression device and/or subcutaneous heparin was used in 99% of patients with compliance being monitored by trauma nurse clinicians. A total of 272 VDS were performed with total charges of $111,520. DVT was found by VDS or venography in eight limbs (2.7%) of six patients (4%), our of the limbs being symptomatic. Two additional patients had pulmonary embolism, both with normal VDS. Routine serial VDS in severely injured patients who undergo aggressive prophylaxis against DVT is not cost effective and therefore not justified.     

Capillaria (Hepatocapillaria) cichlasomae (Nematoda: Capillariidae) from the liver of the cichlid fish Cichlasoma urophthalmus from Yucatan, Mexico

Although various hematological disorders have been considered to be etiologic factors in deep vein thrombosis (DVT), the involvement of dysplasminogenemia (DPG) in DVT has not been studied in detail. In 72 consecutive DVT patients, the presence of DVT was suspected based on a history of lower limb swelling and tenderness with acute onset, and was confirmed by duplex scanning, radioisotope venography, or contrast venography. DPG was identified by the observation of dissociation between the activity and antigenicity of plasminogen. Of the 72 patients, 9 (12.5%) were diagnosed as having DPG, and several antithrombin-III deficiency and protein C and S deficiency were identified. The mean age of the genetically normal and DPG patients was 52 +/- 15 and 40 +/- 15 years, respectively (p < 0.05). Thus, these findings suggest that DPG is deeply related to the development of DVT, and that abnormality of the fibrinolytic system is one of the major etiologic factors in DVT.     

Deep venous thrombosis: incidence on admission to a brain injury rehabilitation program

OBJECTIVE: To determine the incidence of deep venous thrombosis (DVT) in brain injured individuals at time of admission to a brain injury (BI) rehabilitation program. DESIGN: Prospective study, sequential case series. SETTING: University tertiary care BI rehabilitation center. DATA SET: Eighty-two traumatic brain injury (TBI) and 71 atraumatic brain injury (ABI) patients were consecutively admitted to our BI unit over a 12-month period and screened within 24 hours of admission for a lower extremity DVT with color flow duplex Doppler ultrasonography. All patients had been prophylaxed with either subcutaneous heparin anticoagulation therapy or intermittent compression devices, and all patients were within 2 months of the original BI. MAIN OUTCOME MEASURES: Evidence of intrinsic venous occlusion by duplex Doppler. RESULTS: DVTs were detected and treated prior to rehabilitation admission in three patients (2%), and these persisted at rehabilitation admission. New DVTs were detected at time of rehabilitation admission in 17 patients (11%). All were occult DVTs; none of the 17 patients had clinical findings indicative of acute DVT. No significant differences were noted in the TBI group when age, highest 24-hour Glasgow Coma Scale score, length of acute hospitalization, type of DVT prophylaxis, or presence of an extremity fracture were compared for individuals with and without DVT. No significant differences were noted in the ABI group when age, length of acute hospitalization, and type of DVT prophylaxis were compared for individuals with and without DVT. CONCLUSION: The overall incidence of DVTs was 13% and the incidence of occult DVT was 11%. Individuals with TBI had an overall incidence of DVTs of 20% and an occult DVT incidence of 18%. Individuals with ABI had an overall incidence of DVT's of 6% and an occult DVT incidence of 4%. These findings indicate the importance of baseline screening for DVT in this patient population.     

Sonographic incidence of deep venous thrombosis contralateral to hip or knee replacement surgery

PURPOSE: This study assesses the sonographic incidence of deep venous thrombosis (DVT) contralateral to and the venographic incidence ipsilateral to hip or knee replacement surgery and the role of sonography in routine surveillance. METHODS: We prospectively evaluated 178 consecutive patients with sonography of the femoropopliteal venous systems of the contralateral lower extremity and venography of the ipsilateral lower extremity on days 3 and 4, respectively, after total hip or knee replacement surgery. RESULTS: No cases of acute DVT and only 1 case of chronic DVT isolated to the popliteal system were identified by sonography in the contralateral extremity. In the ipsilateral extremity, venography identified 26 patients with acute DVT (3 femoropopliteal, 21 calf, and 2 concurrent femoropopliteal and calf). CONCLUSIONS: Routine sonographic evaluation of the lower extremity contralateral to hip or knee replacement surgery is not cost-effective because of the extremely low incidence of detectable acute thrombus.     

Prevalence of asymptomatic carotid stenosis in patients undergoing infrainguinal bypass surgery

BACKGROUND: The prevalence of asymptomatic carotid stenosis in patients with lower-extremity ischemia is unknown. This report represents the largest carotid screening program to date of patients undergoing leg bypass. DESIGN: Patients undergoing infrainguinal bypass from 1987 through 1993 on the vascular surgery service at Oregon Health Sciences University, Portland, underwent routine carotid duplex examinations to detect the presence of asymptomatic carotid stenosis. PATIENTS: During the study period, 352 patients underwent infrainguinal revascularization for ischemia, of whom 225 (64%) had no prior carotid surgery, carotid arteriography, or cerebrovascular symptoms. There were 117 men and 108 women, with a mean age of 67 years. The indication for surgery was limb salvage in 67% and claudication in 33% of patients. RESULTS: Sixty-four patients (28.4%) who required lower-extremity revascularization had hemodynamically significant asymptomatic carotid artery stenosis or occlusion; 12.4% had stenosis of 60% or greater, the qualifying level for randomization in the Asymptomatic Carotid Atherosclerosis Study. Based on these findings, eight patients with carotid stenosis of 80% or greater underwent elective carotid endarterectomy. There were no postoperative neurologic events in the 225 leg bypass patients. By multivariate logistic regression analysis, the presence of carotid bruit (P < .001) and the presence of rest pain (P = .006) were associated with carotid stenosis of 50% or greater. Limiting screening to patients with carotid bruit, limb salvage indications for surgery, and/or advanced age excluded significant numbers of patients with stenosis; thus, these were not effective screening strategies. CONCLUSION: Screening carotid duplex scanning is indicated in patients who require lower-extremity revascularization.     

Graduated compression stockings in the prevention of deep vein thrombosis in patients with acute myocardial infarction

Venous volume (venous capacity) of the calf is low in patients with acute myocardial infarction, who also have a high risk of deep vein thrombosis (DVT). The effect of graduated compression stockings on the venous volume and on the incidence of DVT was therefore studied in 80 patients aged 70 years and above with acute myocardial infarction. Graduated compression stockings were randomly fitted to one leg, the other serving as a control, after which the venous volume was measured by strain gauge plethysmography. The incidence of DVT was measured by the 125I fibrinogen uptake test. Venous volume was significantly higher in legs treated with graduated compression stockings compared to control legs. DVT developed in eight control legs but not in any leg treated with graduated compression stockings (P = 0.003). DVT was also significantly more frequent in women compared to men and the majority of DVT developed in legs with very low venous volume values.     

Diagnostic imaging in deep vein thrombosis of the limbs

The clinically suspected deep vein thrombosis (DVT) should always be confirmed by instrumental procedures. In fact, about 70% of patients with clinically suspected DVT are shown to be negative on instrumental investigations. Phlebography is still the gold standard in the diagnosis of peripheral DVT. Main phlebographic findings are: persistent filling defect; abrupt interruption of contrast in a vein; lack of opacification in all or some deep veins; flow diversion with opacification of collateral branches. At present, peripheral phlebography is performed when the other noninvasive exams (Color Doppler US and Duplex Doppler) are doubtful, technically limited or when thrombosis of innominate veins or superior vena cava, is suspected. Real-time US enables direct visualization of the limb proximal veins. The venous wall, the venous valves, the thrombus and its development, the anatomic variants, the perivenous structures which may impact on the normal physiology of venous return, are depicted. However, the distal veins of the leg and arm and deep veins (the iliac veins, the superficial femoral vein in the adductor canal) are not accurately visualized. The US findings in DVT include: the presence of echoes within the vascular lumen; the veins in axial scans are not compressible. Pulsed Doppler and duplex Doppler combine the morphologic and functional study. Injury caused by DVT at the valvular level (postphlebitic syndrome) is visualized. Primary deep vein thrombosis caused by valvular disorders (valvular aplasia) is identified. Inadequate superficial and perforating veins to be treated with surgery are mapped. Color Doppler US depicts directly superficial and deep limb veins combining the morphologic with the functional assessment represented by the visualization of the map of flow velocity and direction. Recently, a new diagnostic procedure, the color Doppler Energy (CDE) or Power Doppler has been introduced. Together with mean flow velocity and spectral variance, the signal energy or power is also analyzed. The CDE is independent of the US incidence angle, it does not shows the flow direction, detects particularly slow flows, early canalization of thrombi and non occlusive thrombosis. Color Doppler diagnosis of thrombosis is prompt because an area with absence of color is visualized. Collateral vessels and flow direction within them, is well depicted. Beside the site and extension of thrombosis, color Doppler US is able to directly visualize the distal end of the thrombus, which when floating is at high risk for embolism. CT allows an adequate study of the iliocaval axis and is useful if phlebography or color Doppler US are not diagnostic. Iliocaval thrombosis represents a not infrequent finding during abdominal CT. The thrombus appears as a hypodense mass encircled by the hyperdense rim of contrast medium.     

Prophylactic Greenfield filters: acute complications and long-term follow-up

The efficacy of prophylactic vena caval filters (VCF) in reducing morbidity and mortality from pulmonary embolism (PE) in high-risk trauma patients has been shown, but minimal follow-up data is currently available. VCFs were prophylactically placed in 110 patients between August 1991 and June 1995. There was an early VCF complication rate of 7%. Twenty-two patients died; the remaining 88 patients formed the basis for the follow-up study. Forty-five patients were located and interviewed by phone, and 30 of these patients (34%) returned for evaluation. The mean follow-up time was 18 months (range, 4-42 months). There was no incidence of caval thrombosis on follow-up. Eleven patients had physical findings, and duplex evidence consistent with postphlebitic syndrome. An additional three patients had evidence of old deep venous thrombosis (DVT) by duplex, but no significant symptomatology. VCF are effective in preventing PE related deaths and have few major complications. The long-term morbidity associated with posttraumatic venous thrombosis is significant. This morbidity is related not to PE or VCF, but to the underlying DVT. Improved strategies against DVT are necessary.     

Diagnosis of deep vein thrombosis in elderly hip-fracture patients by using the duplex scanning technique

To detect the incidence of preoperative and postoperative deep vein thrombosis (DVT) in elderly patients with hip fracture, 100 patients aged 65 years and older with either a subcapital or intertrochanteric hip fracture were evaluated by duplex beta-mode ultrasonography. Treatment was based on each scan result: if evidence for DVT was seen, the patient was therapeutically anticoagulated; lacking signs of DVT, patients were treated prophylactically. Before their operation, 77 patients (77%) had normal results of their scans, while DVT was diagnosed in 12 patients (12%). An additional 11 patients (11%) developed DVT after the operation. The total incidence of DVT in this series was 23%.     

Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis

PURPOSE: To evaluate the efficacy of catheter-directed thrombolysis with urokinase in treating symptomatic iliofemoral deep venous thrombosis (DVT). MATERIALS AND METHODS: Twenty-one consecutive patients with iliofemoral DVT underwent treatment for 27 affected limbs (acute DVT, n = 20; chronic DVT, n = 7). The average urokinase dose was 4.9 million IU (range, 1.4 million to 16.0 million IU) infused over an average of 30 hours (range, 15-74 hours). RESULTS: Lysis was complete in 18 (72%), partial in five (20%), and not achieved in two (8%) of 25 treated limbs. Two chronically occluded iliac veins could not be crossed with a guide wire and did not receive urokinase. Sixteen limbs had underlying venous stenoses (> 50%) that were treated with angioplasty (n = 2) or angioplasty and stent placement (n = 14). There were no major complications or clinically detectable pulmonary emboli. The technical and clinical success rates were 85%. CONCLUSION: This initial experience suggests that catheter-directed thrombolysis with urokinase for treatment of symptomatic iliofemoral DVT is safe and effective.     

The development of valvular incompetence after deep vein thrombosis: a follow-up study with duplex scanning

PURPOSE: Duplex ultrasonography with distal cuff deflation was used to establish the physiologic reflux duration in different segments of the deep venous system in healthy individuals, and to document the occurrence of deep vein valve incompetence in patients after deep vein thrombosis (DVT). METHODS: Two hundred fifty-two vein segments in 42 legs of 21 healthy individuals and 160 deep vein segments in 27 patients with phlebographically documented DVT were examined with duplex scanning. RESULTS: The duration of reflux in healthy subjects was significantly shorter in distal deep vein segments. Ninety-five percent of the values were less than 0.88, 0.8, 0.8, 0.28, 0.2, and 0.12 seconds, respectively, for the common femoral, superficial femoral, deep femoral, popliteal, and posterior tibial vein (at midcalf and ankle level). The 95 percentile for reflux duration in the superficial venous system was 0.5 seconds for all vein segments, regardless of the location. No significant correlation was found between the reflux peak flow velocity and reflux duration (R = 0.6). The reflux peak flow velocity is therefore not useful as a parameter of the degree of reflux. The patient group was examined with an interval of 18 to 51 months (mean 34 months) after DVT. Forty-five percent of the initially affected segments showed valve incompetence at follow-up (n = 54); only three of 40 segments initially free from thrombus showed pathologic reflux at follow-up (p < 0.01). Reflux durations in most of the incompetent vein segments were two or more times the normal value of reflux duration. The highest prevalence of valve incompetence was found in the superficial femoral and popliteal vein segment (p < 0.01). None of the patients showed valve incompetence at all levels of the deep venous system. A significant (p = 0.04) relation was found between the extent of the initial thrombosis and the number of refluxing vein segments at follow-up, but no correlation was found between the extent of initial thrombosis and the late clinical symptoms (p = 0.16); clinical symptoms could not be related to the number of incompetent vein segments. CONCLUSIONS: Duplex scanning allows a good discrimination between physiologic and abnormal reflux duration and is an important tool in the evaluation of the postthrombotic limb. Early assessment after DVT may have prognostic value in individual patients.     

Deep venous thrombosis: prediction by D-dimer?

The utility of D-dimer as an inexpensive, noninvasive method of diagnosing deep venous thrombosis (DVT) is debated. We sought to determine whether a qualitative D-dimer assay would have a high correlation with DVT in 65 hospitalized patients who were randomly referred for diagnosis of DVT by venous duplex and duplex Doppler ultrasonography. Patients were excluded from the study if they had any inflammatory, infectious, or malignant condition associated with elevation of D-dimer. The mean level of D-dimer in patients with DVT (16 of 65 patients) was 5,141 ng/mL, compared with 3,024 ng/mL in those without DVT, but there was considerable overlap between the two groups. No patients with a D-dimer level < 2,000 ng/mL had DVT. We conclude that the qualitative D-dimer assay is an excellent exclusionary test for DVT at levels less than 2,000 ng/mL. Limitations of the D-dimer assay and cost-effective issues are discussed.     

Combined use of leg scanning and impedance plethysmography in suspected venous thrombosis. An alternative to venography

Venography is the standard method for the diagnosis of venous thrombosis but is invasive and may cause discomfort. We evaluated the combination of impedance plethysmography and 125I-fibrinogen leg scanning as an alternative to venography in 200 symptomatic patients. One or both of these less invasive tests was positive in 81 of 86 patients with positive venograms (sensitivity of 94 per cent) and both were negative in 104 of 114 patients with negative venograms (specificity of 91 per cent). These two tests detected all 60 patients with popliteal or more proximal venous thrombosis and 21 of 26 patients with calf-vein thrombosis. In addition, this approach detected 21 of 22 patients with calf-vein thrombosis with symptoms for eight days or less. These results suggest that the combination of these two less invasive tests can be used as an alternative to venography in selected patients with clinically suspected venous thrombosis.     

Severe non-ketotic hyperosmolar coma--intensive care management

We prospectively studied 266 hands in 133 patients with carpal tunnel syndrome (CTS) in order to evaluate: the incidence of bilateral CTS symptoms; correlation between severity, duration of symptoms and bilateral occurrence of CTS; agreement of clinical and neurophysiological findings; and the neurophysiological findings in asymptomatic hands in unilateral CTS. The incidence of bilateral clinical CTS in our population was 87%. Neurophysiological impairment of median nerve was observed in about half of the asymptomatic hands. Follow-up of patients with unilateral CTS showed that contralateral symptoms developed in most cases. We found a significant positive correlation of bilateral CTS with the duration of symptoms, whereas there was no correlation with the severity of symptoms. Our data suggest that bilateral impairment of median nerve is the rule in patients with CTS and probably it has been underestimated in previous studies.     

Routine bilateral exploration for inguinal hernia in infancy and childhood

Whether to explore the contralateral side is a real question regarding the management of unilateral inguinal hernias in infants and children. The surgeon can easier make a decision if he knows the true incidence and prevalence of the bilateral involvement in different ages. During the years 1982 to 1991 the authors could find 138 contralateral hernias developed after unilateral herniorrhaphy in 2554 children (5.4%). Fifty-five percent of these children (76 patients) were younger than 1 year of age, 74% of them (102 patients) were younger than 3 years of age at the time of the initial repair. The interval between the operations was less than 1 year in 54% of the cases. To get more precise data, we explored 148 children younger than 3 years of age bilaterally during 1992. The result was positive in 104 cases (70.3%). The bilateral involvement was most frequent under the first 6 months of life (83.5%), then it dropped gradually. We found a patent processus vaginalis on the asymptomatic side in 74.3% of girls and in 61.1% of boys. The overall contralateral involvement of unilateral hernias was 64.8%, independently of which side the hernia had appeared on. The patent processus vaginalis can be regarded as a precursor of indirect hernias, so the contralateral exploration can prevent the development of a later hernia. The authors conclude that bilateral exploration is mainly justified during infancy, but in case of girls they suggested applying it until three years of age.     

Management of deep vein thrombosis of the lower extremity in pregnancy: a challenging dilemma

This study reviews our experience in the management of deep vein thrombosis (DVT) of the lower extremity during pregnancy and analyzes the outcome of various treatment alternatives, including conventional full-dose heparin therapy and Greenfield filter insertion. Twenty-four patients treated over an 8-year period were reviewed. Fifteen patients were treated with conventional full-dose intravenous heparin therapy for 5 to 10 days, followed by subcutaneous low-dose heparin until labor, and continued for 6 weeks postpartum (Group A); Eleven patients had Greenfield filters inserted, followed by the same low-dose subcutaneous heparin regimen (Group B). There were 18 femoral or iliofemoral, 5 femoropopliteal, and 1 popliteal and below-knee DVT. The indications for Greenfield filter insertion included two patients in Group A (one with pulmonary embolism, despite adequate heparin therapy, and one with significant bleeding). Nine other patients had prophylactic indications: two for free-floating iliofemoral DVT, three with iliofemoral DVT (occurring just 1-2 weeks before labor), and four with femoropopliteal DVT. There were three immediate major complications (pulmonary embolism, bleeding, or death) in Group A; two with pulmonary embolism, one of which was fatal, and one with significant bleeding (3 of 15 patients; 20%). No major complications occurred in Group B. On long-term follow-up (mean, 61 months), 4 of 12 patients (33%) in Group A had significant leg swelling, with partial resolution of DVT in 2 patients and venous occlusion in 2 patients by duplex ultrasound. This is in contrast to 3 of 11 patients (27%) in Group B with significant leg swelling. There was no fetal morbidity or mortality in either group. Conventional full-dose heparin therapy for DVT of the lower extremity in pregnancy can carry significant morbidity and mortality. Greenfield filters may be used safely in some of these patients.     

Popliteal artery aneurysms

Altogether 59 patients with 76 popliteal artery aneurysms were treated during the last 36 years. There were 50 (85%) male and 9 (15%) female patients with an average age of 61 years. Nineteen (32%) patients had bilateral aneurysms. The clinical manifestations of the aneurysms included ruptures 4 (5.3%); deep venous thrombosis 4 (5.3%); sciatic nerve compression 1 (1.3%); leg ischemia 52 (68.4%), and asymptomatic pulsatile masses 15 (19.7%). Seventy (92%) aneurysms were atherosclerotic, one (1.3%) mycotic, and four (5.3%) traumatic; one (1.3%) developed owing to fibromuscular displasia. Seven (9.2%) small, asymptomatic aneurysms were not operated on. Reconstructive procedures end-to-end anastomosis, graft interposition, bypass) after aneurysmal resection or exclusion using a medial or posterior approach were done in 59 cases. An autologous saphenous vein graft was used in 49 cases, polytetrafluoroethylene (PTFE) in 5, and heterograft in 2 cases. The in-hospital mortality rate was 2.9%, the early patency rate 93.3%, and limb salvage 95%. The long-term patency rate after a mean follow-up of 4 years was 78% and long-term limb salvage 89%. The total limb salvage was 73%, and the total amputation rate was 27%. The dangerous complications associated with popliteal artery aneurysms and the good results after elective procedures suggest that operative treatment is appropriate.     

Hydroxyurea for treatment of unresectable and recurrent meningiomas. I. Inhibition of primary human meningioma cells in culture and in meningioma transplants by induction of the apoptotic pathway

PURPOSE: Venous aneurysms have been reported to occur in most major veins. These aneurysms may be misdiagnosed as soft tissue masses or as inguinal or femoral hernias. Venous aneurysms of the deep system have been associated with deep venous thrombosis (DVT) and pulmonary embolism (PE). To more precisely characterize these lesions, we reviewed our experience with the disease. METHODS: A retrospective analysis of our experience over 22 years was performed. The presentation and management of these lesions were reviewed and compared with the literature. RESULTS: Thirty-nine venous aneurysms were reported in 30 patients. There were 14 men and 16 women. The patients' ages ranged from 3 to 75 years. Thirty aneurysms were located in the lower extremities, four in the upper extremity, and five in the internal jugular vein. Fifty-seven percent of lower extremity aneurysms occurred in the deep system. Patients' symptoms were a mass (75%) associated with pain (67%) and swelling (42%). Thromboembolism occurred in six patients, DVT in three, and PE in three. Eight of nine patients (89%) who had aneurysms of the superficial venous system had their condition misdiagnosed. Diagnosis was made by phlebography (60%), color flow duplex scanning (27%), continuous-wave Doppler scanning (10%), or magnetic resonance imaging (10%). The aneurysm size ranged from 1.7 to 6.0 cm. Management consisted of tangential excision in five (17%), total excision in 23 (77%), and observation in seven (6%). CONCLUSIONS: Venous aneurysms are unusual vascular malformations that occur equally between the sexes and are seen at any age. Most patients have a painful mass of the extremity, and diagnosis is achieved by radiologic examination. Superficial venous aneurysms of the inguinal region are often misdiagnosed. Thromboembolism is more common in aneurysms involving the deep venous system. Because of their potential morbidity, management should be surgical in the majority of cases.