Epidemiological study of angioedema and ACE inhibitors

A total 30,040 pregnancies were reviewed at one institution over 5 years to determine the incidence of venous thrombotic complications. Thirty-one patients experienced such complications related to pregnancy (incidence 0.1%); 13 had deep venous thrombosis and 14 had superficial venous thrombophlebitis diagnosed by duplex ultrasound. Four had pelvic vein thrombophlebitis diagnosed by computed tomography scan; three patients (one from each group) sustained a non-fatal pulmonary embolus. Of those with deep venous thrombosis, 10 (77%) were left-sided, and three (23%) were right-sided. Three had a prior history of deep venous thrombosis and one of pulmonary embolism. Of those with superficial venous thrombophlebitis, seven (50%) were left-sided, six (43%) were right-sided, and one (7%) was bilateral. Most with deep venous thrombosis presented later in pregnancy; three in the first trimester, two in the second, three in the third, and five early postpartum. Most (10/14) with superficial venous thrombophlebitis presented within 48 hours of delivery. Distribution of thrombi in those with deep venous thrombosis was compared with 643 non-pregnant women with a similar condition. A pattern of proximal involvement on the left was found, with left common femoral vein (54% versus 28%, P = 0.03) and superficial femoral vein (62% versus 26%, P = 0.006) more often involved in pregnant patients. The average number of vein segments involved was greater on the left than the right (5.3 versus 3.7). Symptoms of chronic venous insufficiency developed in three with deep venous thrombosis (25%) and in three with superficial venous thrombophlebitis (27%). None had recurrence of deep venous thrombosis. It is concluded that venous thrombotic complications associated with pregnancy are not necessarily benign, with the risk of pulmonary embolism and chronic venous insufficiency not limited to patients with deep venous thrombosis only.     

Diagnosis of venous thrombosis in the legs using 81Krm venography

Contrast venography, the accepted gold standard for the diagnosis of venous thrombosis of the leg, is a painful and invasive procedure with late side effects. There is controversy in literature reports about the sensitivity of 99Tcm-macroaggregated albumin (MAA) phlebography: indeed, using 99Tcm-MAA, poor results are obtained when one has to detect calf vein thrombosis. As with other isotopic procedures requiring a pedal injection of the tracer, the use of an injectable solution of 81Krm is a nonspecific method, based upon the abnormality in flow in the deep venous system which results from a deep venous thrombosis. However, when compared with 99Tcm-MAA, 81Krm offers theoretical advantages for phlebographic studies of the lower limbs. In this work 24 patients were studied both with contrast phlebography and with 81Krm. Although 81Krm provided images of high quality, there was a lack of sensitivity below the knee, where false negative results were observed. This could be explained by the fact that the radionuclide venographic procedures usually visualize only one or, in some cases, two of the three deep veins of the calf. Moreover, accurate differentiation between superficial and deep veins in the calf often appears difficult, even using a tourniquet.     

Superficial veins of the lower limbs

This study, limited to the superficial veins of 123 limbs (108 normal and 15 suffering from frank varicose disease) and only vessels with a caliber of at least 2 mm, reveals a certain degree of constancy of anatomical pattern. The initial network is defined embryologically and subsequent haemodynamic phenomena model the final veins. In particular, the topography of the main perforating veins is relatively fixed. Due to their double antihypertensive valve and aspirating pump function while walking, these vessels drain into saphenous veins. They are beneficial when they return reflux into the deep vessels. Conversely, perforator incompetence contaminates the superficial network in the case of deep reflux. The perforating vessels also have a relatively fixed position in relation to other structures: the main saphenous collateral veins, their duplicated branches, their communicating veins and the main valves. This results in large junctions typically associating a saphenous valve, one or several collateral veins, one or several communicating veins, and one or several perforating veins. Typical examples are the garter junction for the long saphenous vein, and the junction of the tip of the calf for the short saphenous vein. Other haemodynamic levels are situated at various sites, particularly in the leg, reflecting the existence, in some cases, of symmetrical "mirror", medial and lateral perforating veins. Morphological analysis of 15 limbs with obvious varicose veins of the trunk of the long saphenous vein defined the routes of transmission of reflux to the leg. Finally, the authors present several technical considerations which they hope will be useful for Doppler operators and surgeons.     

Different risks of thrombosis in four coagulation defects associated with inherited thrombophilia: a study of 150 families

Deficiency of the naturally occurring anticoagulant proteins, such as antithrombin, protein C and protein S, and activated protein C resistance due to the factor V Leiden gene mutation is associated with inherited thrombophilia. So far, no direct comparison of the thrombotic risk associated with these genetic defects is available. In this study, we wish to compare the lifetime probability of developing thrombosis, the type of thrombotic symptoms, and the role of circumstantial triggering factors in 723 first- and second-degree relatives of 150 index patients with different thrombophilic defects. We found higher risks for thrombosis for subjects with antithrombin (risk ratio 8.1, 95% confidence interval [CI], 3.4 to 19.6), protein C (7.3, 95% CI, 2.9 to 18.4) or protein S deficiency (8.5, 95% CI, 3. 5 to 20.8), and factor V Leiden (2.2, 95% CI, 1.1 to 4.7) than for individuals with normal coagulation. The risk of thrombosis for subjects with factor V Leiden was lower than that for those with all three other coagulation defects (0.3, 95% CI, 0.1 to 1.6), even when arterial and superficial vein thromboses were excluded and the analysis was restricted to deep vein thrombosis (0.3, 95% CI, 0.2 to 0.5). No association between coagulation defects and arterial thrombosis was found. The most frequent venous thrombotic manifestation was deep vein thrombosis with or without pulmonary embolism (90% in antithrombin, 88% in protein C, 100% in protein S deficiency, and 57% in factor V Leiden), but a relatively mild manifestation such as superficial vein thrombosis was common in factor V Leiden (43%). There was a predisposing factor at the time of venous thromboembolism in approximately 50% of cases for each of the four defects. In conclusion, factor V Leiden is associated with a relatively small risk of thrombosis, lower than that for antithrombin, protein C, or protein S deficiency. In addition, individuals with factor V Leiden develop less severe thrombotic manifestations, such as superficial vein thrombosis.     

Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound

BACKGROUND: Two different diagnostic strategies are used to perform compression (real-time) ultrasound for the diagnosis of clinically suspected deep-vein thrombosis. One is to examine the entire proximal venous system from common femoral to distal popliteal vein; the other is a limited examination of only the common femoral and the entire popliteal vein. The latter strategy, which is less time-consuming and requires less expensive equipment, is based on a strong impression from prospective studies using limited compression ultrasound that proximal vein thrombi always involve the common femoral or popliteal vein. This impression, which is supported by the demonstrated safety at long-term follow-up of not treating patients whose limited compression ultrasound is normal at presentation and then repeated within the next week, has not been tested in a formal study. Therefore, we reviewed a large series of venograms performed in consecutive patients with clinically suspected venous thrombosis to determine the distribution of venous thrombosis in symptomatic patients. METHODS: Venograms were performed using 150 mL of radiographic contrast material. Before the study, a panel of experts agreed on the standardized criteria for the assessment of venograms. Venograms were adjudicated blindly for the presence of deep vein thrombosis and to determine the distribution of proximal vein thrombosis and isolated calf-vein thrombosis, the size of proximal thrombi, and whether they were occlusive or nonocclusive. Subsequently, the duration of symptoms was related to the venographic findings. RESULTS: Five hundred sixty-two venograms from consecutive patients with a first episode of clinically suspected deep vein thrombosis were adjudicated. Of these, 20 (3.6%) were inadequate for interpretation. In the remaining 542, venous thrombosis was demonstrated in 189 instances (prevalence, 35%; 95% confidence interval, 31% to 39%) and were located in the proximal veins in 166 (88%; 95% confidence interval, 82% to 92%) venograms. Isolated calf-vein thrombosis was present in the remaining 23 (12%; 95% confidence interval, 8% to 18%) venograms. Proximal with concurrent calf thrombosis was detected in 164 (99%) of the 166 patients. Proximal thrombi involved only the popliteal vein in 16 (10%); the popliteal and superficial femoral veins in 70 (42%); and the popliteal, superficial, and common femoral vein in eight (5%); whereas thrombi involving the entire proximal deep venous system were detected in 58 (35%) venograms. Isolated thrombosis of the superficial femoral, common femoral, and iliac vein was not observed. Proximal venous thrombi were occlusive in 146 (88%) patients. No relation between the duration of symptoms and the extent or the occlusiveness of venous thrombi could be demonstrated. CONCLUSIONS: Most symptomatic patients have extensive occlusive proximal vein thrombosis at the time of presentation. Thrombi isolated to the superficial femoral or iliac vein were not observed in this large sample of consecutive patients. Our data support the use of the relatively simple, inexpensive, and rapid compression ultrasound method that limits the examination of the proximal veins to the common femoral and popliteal veins.     

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.     

Ulcus cruris--vascular etiology and surgical treatment options

Leg ulcers comprise a problem with various contributing factors requiring selective therapy adapted to the underlying cause. The majority can be classified as arterial (approx. 20%) or venous (approx. 80%) ulcers. Arterial ulcers as well as most mixed (arterial-venous) ulcers can be treated by arterial reconstruction and subsequent skin grafting, with additional ligation of perforator veins or (segmental) stripping of the saphenous vein. Leg ulcers due to chronic insufficiency of the deep venous system are most often the result of previous deep venous thrombosis followed by recanalization and development of a postthrombotic syndrome. Compression regimens remain standard therapy with emphasis on preventing ulcer formation. Ulcer healing can be achieved by compression therapy although recurrence rates are high. Surgery is not the treatment of first choice for leg ulcers, however, in selected cases surgical therapy is indicated. To prevent recurrence, continued consistent compression, keeping the patient well-informed and offering supportive guidance are imperative.     

Isolated plantar venous thrombosis. Report of a case

We report the case of a patient with isolated plantar thrombophlebitis as a post operative complication of saphenectomy. Risk factors such as prolonged bed rest, perioperative inflammation and surgery of the greater saphenous vein itself should be considered. Moreover multiple episodes of superficial venous thrombosis had already occurred as complication of the superficial venous insufficiency. Literature on this unusual outcome is lacking. Ultrasound imaging revealed this superficial thrombosis. Usual echographic signs (non compressible vein, hypoechogenicity of the vessel lumen) can be found. The main problem is to differentiate veins from adjacent tendinous structures. Slow mobilisation of the toes and comparative analysis on contralateral foot are helpful. Thrombosis of the plantar veins must be considered as a possible diagnosis of unexplained plantar unilateral pains. Development of ultrasonic investigations and knowledge of its occurrence could further improve its diagnosis.     

Prevalence and clinical significance of posterolateral thigh perforator vein incompetence

PURPOSE: Posterolateral thigh perforator (PLTP) veins are part of the lateral thigh venous system, which in most people remains undeveloped. This study was designed to determine the prevalence and clinical significance of these veins. METHODS: Over the past 6 years, 2820 lower limbs with signs and symptoms of chronic venous disease (CVD) were evaluated for venous reflux using color flow duplex imaging. Superficial, perforating, and deep veins were examined in the standing, sitting, and reversed Trendelenburg positions. PLTP veins were best identified in the standing position with the patient facing away from the examiner. RESULTS: Twenty-six incompetent PLTP veins were found in 24 limbs (0.85%) of 21 patients (mean age, 43 +/- 16 years; range, 22 to 77 years). All PLTP veins pierced the fascia lata 12 to 25 cm (mean, 16 +/- 3 cm) above the popliteal skin crease in the lateral aspect of the thigh. At this level, the PLTP veins dove posteriorly 3 to 8 cm to join primarily tributaries of the deep femoral vein, superficial femoral vein, or both. Eight PLTP veins were duplicated at 1 to 2 cm below the fascia. Seven PLTP veins gave rise to superficial tributaries that were extended to the lower lateral and posterior thigh, whereas the remaining 19 PLTP veins gave rise to tributaries alongside the lesser saphenous vein and the anterior arch of the greater saphenous vein. On nine occasions, reflux was found in the PLTP veins and their associated tributaries alone. In all of these cases, reflux was adequately controlled with a tourniquet placed distal to the fascial defect. In the remaining 17 PLTP veins, reflux was also seen in the greater saphenous vein, the lesser saphenous vein, or both. None of the limbs that had PLTP vein reflux alone exceeded CVD class 3. When PLTP vein reflux was combined with saphenous reflux, there were five limbs classified as CVD class 4 and one limb each as CVD classes 5 and 6. Twenty limbs underwent ligation and stripping of the varicosities. Three of the earlier patients in the series underwent incomplete operations, which resulted in immediate residual varicosities from the PLTP tributaries. All three patients underwent reoperation successfully within a year. CONCLUSIONS: The prevalence of PLTP vein reflux is quite low. Reflux in the PLTP veins alone is associated with mild to moderate clinical presentation. However, when it is combined with saphenous reflux skin damage can be present. Failure to recognize PLTP veins may result in an incomplete or unnecessary operation, leaving the patients with residual varicose veins.     

Normal and pathological anatomy and physiology of the veins of the lower limbs

Veins of the lower limbs are divided into two regions: 1) the superficial region, composed of two saphenous veins, internal and external, and of their tributaries; 2) the deep region, composed of veins that are satellites (and homonyms) of the arteries (anterior and posterior tibial; peroneal; popliteal; superficial, deep and common femoral; external, epigastric and common iliac). The two networks are linked by perforating (or communicating) veins and by the arches of the two saphenous veins. Valvules are found in the venous network below the inguinal ligament; their number decreases with increasing proximity to the inferior vena cava. The function of the valves is the main factor in the physiology of venous circulation, in association with the force essentially provided by the "muscle pump" of the calf. The various forms of venous insufficiency are due to obstruction or incontinence of the veins.     

Minimally invasive cardiac surgery: current status and perspective

This study investigated the features of calf deep vein thrombosis (DVT) as a pulmonary embolic source. Fifty-eight lower limbs in 29 patients who were suspected of having DVT distal to the popliteal vein were screened by ultrasonography. Then, ascending venography was performed to confirm the diagnosis. Pulmonary embolism (PE) was diagnosed in suspected patients by use of pulmonary perfusion scanning or pulmonary angiography. Venography revealed calf DVT in 33 limbs in 28 patients. Of 28 patients, six had symptomatic PE. Thrombosis was found in the muscle veins in 18 limbs, the trunk veins in 11, and both veins in four. Isolated single vein thrombosis was found in the soleal vein in 14 limbs (42%), the posterior tibial vein in eight, the peroneal vein in two, and the gastrocnemius vein in two. The overall percentage of soleal vein thrombi was 61%. All six patients with symptomatic PE had isolated soleal vein thromboses. Calf DVT was a pulmonary embolic source when isolated thrombosis of the large soleal vein was more than 7 mm in diameter. Soleal veins were the most frequent and important location of calf DVT, suggesting that these were an occasional embolic source of critical PE.     

Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study

OBJECTIVE: To evaluate the safety of withholding anticoagulant treatment from patients with clinically suspected deep vein thrombosis but normal findings on compression ultrasonography. DESIGN: Compression ultrasonography was done with a simplified diagnostic procedure limited to the common femoral vein in the groin and the popliteal vein extending down to the trifurcation of the calf veins. Patients with normal ultrasonography findings at presentation were retested 1 week later. MAIN OUTCOME MEASURE: The incidence of venous thromboembolic complications during follow up for 6 months in patients in whom anticoagulant treatment was withheld on the basis of normal results on two ultrasonography tests 1 week apart. SETTING: University research centres in four hospitals. RESULTS: A total of 1702 patients were included in the study. Abnormal results on compression ultrasonography at presentation or at 1 week were found in 400 and 12 patients, respectively, for a prevalence of deep vein thrombosis of 24%. None of the patients were lost to follow up. Venous thromboembolic complications during the week of serial testing occurred in a single patient and in eight patients during 6 months' follow up, resulting in a cumulative rate of venous thromboembolic complications of 0.7% (95% confidence interval 0.3% to 1.2%). The mean number of extra hospital visits and additional tests required per initially referred patient was 0.8. CONCLUSION: It is safe to withhold anticoagulant treatment from patients with clinically suspected deep vein thrombosis who have a normal result on compression ultrasonography at the time of presentation and at 1 week.     

Colour duplex ultrasonography in the rational management of chronic venous leg ulcers

Colour duplex ultrasonographic imaging has largely replaced venography in the assessment of lower-limb venous disorders. This is a study of the use of duplex in the management of patients with chronic venous ulceration in community ulcer clinics. Patients with chronic leg ulceration and an ankle: brachial pressure index of 0.85 or greater were studied. Assessment of venous competence in both the deep and superficial systems of the affected and unaffected legs was performed using colour venous duplex imaging. Reflux was defined as reverse flow for greater than 1 s after manual calf compression. One hundred consecutive patients were assessed over 15 months. Of 111 ulcerated legs, 96 had active ulceration, while 15 had been ulcerated within the previous 6 months. Fifty-seven (51 per cent) of the 111 ulcerated legs had superficial incompetence alone (88 per cent long saphenous system or its perforators, 12 per cent short saphenous system). Six legs (5 per cent) had isolated deep venous incompetence. Forty-two legs had mixed superficial and deep venous reflux; 22 of these had undergone previous venous surgery. Colour venous duplex assessment demonstrated superficial venous disease in approximately half of limbs with chronic leg ulceration. Venous dysfunction in these patients is potentially curable by surgery.     

How often is thrombolytic therapy of deep pelvic-leg venous thrombosis indicated?

BACKGROUND: For patients with deep vein thrombosis new thrombolytic regimes are being proposed and demand evaluation in controlled studies. We tested prospectively, how many patients in internal medicine are candidates for thrombolysis. PATIENTS AND METHODS: All available patients with the diagnosis of deep vein thrombosis (DVT) in lower extremities who were admitted to the service of internal medicine in a medium-sized hospital during one year were prospectively evaluated for the indication of fibrinolysis therapy according to the established criteria. RESULTS: A total of 62 patients were enrolled. Fibrinolysis was not proposed in 25 patients aged over 70 years nor in another 9 patients in whom the thrombosis was restricted to calf veins. Nine additional cases had a recurrence of DVT (n = 4) or a history of more than 14 days. Among the remaining 19 patients, fibrinolysis was not performed in 11 because of advanced malignomas (n =4) or other diseases (n = 3) with limited life expectance, enhanced probability of haemorrhage (n = 3) and obvious non-compliance (n = 1). Eight patients were offered thrombolytic therapy, but 5 of them denied consent after being comprehensively informed. CONCLUSION: Obviously by far most of patients admitted to internal medicine for DVT are candidates for standard heparin therapy only.     

Color duplex ultrasound in the assessment of primary venous leg ulceration

METHODS: To determine the extent and severelity of venous reflux, color duplex ultrasound was used in 370 limbs of 303 patients with primary varicose veins. The clinical findings were classified according to the CEAP (clinical, etiologic, anatomic, pathophysiologic) clinical classification. RESULTS: Of 370 limbs, 32 showed previously healed ulcer (Class 5) and active ulcer (Class 6). Overall reflux in the superficial venous system was seen in 28 limbs (87.5%), and solitary superficial vein incompetence was detected in 13 (40.6%). Reflux was detected throughout the length of the superficial vein system, and the retrograde peak velocity was greater than 30 cm/second in these limbs. Reflux in the perforating veins was detected in 14 limbs (43.8%), but isolated perforating vein incompetence was seen in only one limb (3.1%). Deep vein incompetence was detected in 12 limbs (37.5%). Concomitant superficial and perforating vein reflux was evident in 4 limbs (12.5%) and 2 limbs (6.3%), respectively, but isolated deep vein incompetence was detected in only one limb (3.1%). The operations indicated were selective stripping of the long saphenous vein in the thigh, high ligation of the short saphenous vein, subfascial ligation of perforating veins, and compression sclerotherapy for varicose tributary veins. Healing of the ulcers was achieved within 1 month after surgery, and the postoperative color duplex scanning revealed correction of deep vein incompetence. CONCLUSIONS: These data suggest that ablation of the superficial vein system and the perforating veins is an appropriate method for the management of patients with primary venous leg ulceration.     

Clinical diagnosis of deep venous thrombosis after hip replacement surgery

Hip replacement surgery is associated with a high frequency of postoperative deep vein thrombosis. This prospective study was performed in order to investigate if routine bedside questioning and examination by the visiting doctor could reveal deep vein thrombosis in the legs of patients who had received a hip replacement. 258 patients were evaluated. Thromboprophylaxis (dextran-70, low molecular weight heparin and graded elastic stockings) was given during the first week after operation. Bilateral venography was performed in all patients on day seven after operation, and showed an overall deep vein thrombosis incidence of 16%. The visiting doctors had not suspected deep vein thrombosis in any of the patients. This may have been because postoperative painful and swollen legs effectively masked any signs and symptoms of deep vein thrombosis. Our results show that deep vein thrombosis during the first week after hip replacement surgery cannot be discovered by clinical diagnostics. The high subclinical frequency of deep vein thrombosis indicates the importance of improving thromboprophylaxis in order to further minimise the occurrence of deep vein thrombosis and the risk of thromboembolic complications.     

High levels of histidine-rich glycoprotein and thrombotic diathesis. Report of two unrelated families

Two new families with history of thrombosis and high levels of histidine-rich glycoprotein (HRG) are described. The propositus of family 1 died of massive pulmonary embolism at age 34. Among his relatives, the mother and the maternal grandmother had suffered from deep and superficial vein thrombosis in their youth. A maternal aunt had several episodes of superficial vein thrombosis (SVT). High levels of HRG were found in the mother, three siblings and two nephews. In the second family, the proposita suffered from spontaneous deep vein thrombosis (DVT) at age 24. The paternal grandmother and a paternal aunt had several episodes of SVT and DVT. Also in this family, high levels of HRG cosegregated with thrombotic symptoms. These new families confirm that genetically transmitted high levels of HRG could be associated to familial and juvenile thrombophilia.     

Physiologic variations in lower extremity venous valvular function

We conducted this study to investigate the physiologic variations in venous valvular function and calf muscle pump function that occur in normal limbs after prolonged stationary standing. Twenty-two limbs from 11 healthy volunteers were studied after a brief period of activity and after 4 to 6 hours of stationary standing. Vein diameter, peak reflux flow velocity (PRFV), and valve closure time (VCT) were measured with duplex scanning in the standing position in the common femoral vein (CFV), superficial femoral vein (SFV), popliteal vein (POP), proximal greater saphenous vein (GSV), and greater saphenous vein at the knee (kGSV). Pneumatic rapid inflation-deflation cuffs were used to elicit reflux. Vein cross-sectional area (VA) and peak reflux volume (PRVol) were calculated. Venous volume (VV), venous filling index (VFI), ejection fraction (EF), residual volume fraction (RVF), and outflow fraction (OF) were measured with air plethysmography in all limbs. After stationary standing, there was no significant change or trend toward an increase in diameter or VA in any of the deep veins and there was no change in the PRFV or VCT. In the proximal GSV there was a significant increase in diameter (p = 0.0001) and VCT (p = 0.048) without a change in PRFV. No significant changes were noted in the kGSV. In the GSV the PRFV was significantly lower (p < 0.05) and the VCT significantly shorter (p < 0.05) compared with the SFV and POP but values were no different from those in the CFV. The PRFV was significantly higher in the SFV (p < 0.0001) and the POP (p < 0.002) compared with that in the CFV.(ABSTRACT TRUNCATED AT 250 WORDS)     

Organization and expression of basement membrane collagen IV genes and their roles in human disorders

PURPOSE: The prevalence of reflux in the deep and superficial venous systems in the Edinburgh population and the relationship between patterns of reflux and the presence of venous disease on clinical examination were studied. METHODS: A cross-sectional survey was done on men and women ranging in age from 18 to 64 years, randomly selected from 12 general practices. The presence of varicose veins and chronic venous insufficiency was noted on clinical examination, as was the duration of venous reflux by means of duplex scanning in 8 vein segments on each leg. Results were compared using cut-off points for reflux duration (RD) of 0.5 seconds or more (RD >/= 0.5) and more than 1.0 second (RD > 1.0) to define reflux. RESULTS: There were 1566 study participants, 867 women and 699 men. The prevalence of reflux was similar in the right and left legs. The proportion of participants with reflux was highest in the lower thigh long saphenous vein (LSV) segment (18.6% in the right leg and 17.5% in the left leg for RD >/= 0.5), followed by the above knee popliteal segments (12.3% in the right leg and 11.0% in the left leg for RD >/= 0.5), the below knee popliteal (11.3% in the right leg and 9.5% in the left leg for RD >/= 0.5), upper LSV (10.0% in the right leg and 10.8% in the left leg for RD >/= 0.5) segments, the common femoral vein segments (7.8% in the right leg and 8.0% in the left leg for RD >/= 0.5), the lower superficial femoral vein (SFV) segments (6.6% in the right leg and 6.4% in the left leg for RD >/= 0.5), and the upper SFV (5.2% in the right leg and 4.7% in the left leg for RD >/= 0.5) and short saphenous vein (SSV) (4.6% in the right leg and 5.6% in the left leg for an RD >/= 0.5) segments. In the superficial vein segments, there was little difference in the occurrence of reflux whether RD >/= 0.5 or RD > 1.0 was used; but in the different deep vein segments, the prevalence of reflux was 2 to 4 times greater for RD >/= 0.5 rather than RD > 1.0. Men had a higher prevalence of reflux in the deep vein segments than women, reaching statistical significance (P /= 0.5. In general, the prevalence of reflux increased with age. Those with "venous disease" had a significantly higher prevalence of reflux in all vein segments than those with "no disease" (P 相似文献   

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.