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Introduction: Pelvic varicose veins, one of the main causes of chronic pelvic pain and dyspareunia, are an important source of reflux for lower limb varicose veins, especially in recurrent cases. Color Doppler ultrasound of the lower limbs and transvaginal ultrasound are the noninvasive diagnostic methods most commonly used to assess pelvic venous insufficiency, whereas phlebography is still considered as the gold standard. Objectives: To determine the prevalence of lower limb varicose veins originating from the pelvis in a group of female patients and to determine the agreement between results obtained via color Doppler ultrasound of the lower limbs, transvaginal ultrasound, and phlebography. Methods: The sample comprised female patients referred to a vascular laboratory for lower limb screening. Patients diagnosed with deep venous thrombosis were excluded. Data analysis included kappa coefficient of agreement, McNemar's test, sensitivity and specificity values. Results: Of a total of 1,020 patients, 124 (12.2%) had findings compatible with reflux of pelvic origin. Among these patients, 51 (41.2%) were recurrent cases. A total of 249 were submitted to transvaginal ultrasound. There was significant agreement between lower limb ultrasonographic findings and transvaginal findings. Phlebography was performed in 54 patients. The comparison between transvaginal ultrasound and phlebography was associated with a 96.2% sensitivity and 100% specificity. Conclusions: The authors draw attention to the relatively high prevalence of lower limb varicose veins originating from the pelvis, suggesting an important but underdiagnosed cause of recurrent varicose veins. Introdução: AS VARIZES Pélvicas, uma das principais causas de dor pélvica crônica e dispareunia, são uma importante fonte de refluxo para as varizes dos membros inferiores, especialmente em casos recorrentes. O Doppler colorido dos membros inferiores e o ultrassom transvaginal são os métodos diagnósticos não-invasivos mais comumente usados para avaliar a insuficiência venosa pélvica, enquanto a flebografia ainda é considerada como o padrão-ouro. Objetivos: Determinar a prevalência de varizes dos membros inferiores originadas na pélvis em um grupo de pacientes do sexo feminino e determinar a concordância entre os resultados obtidos por Doppler colorido dos membros inferiores, ultrassom transvaginal e flebografia. Métodos: A AMOstra incluiu pacientes do sexo feminino encaminhadas para o laboratório vascular para triagem dos membros inferiores. As pacientes diagnosticadas com trombose venosa profunda foram excluídas. A análise dos dados incluiu o coeficiente de concordância kappa, o teste de McNemar e os valores de sensibilidade e especificidade. Resultados: De um total de 1.020 pacientes, 124 (12.2%) tiveram achados compatíveis com refluxo de origem pélvica. Entre essas pacientes, 51 (41.2%) eram casos recorrentes. Um total de 249 foram submetidas a ultrassom transvaginal. Houve concordância significativa entre os achados ultrassonográficos dos membros inferiores e os achados transvaginais. A flebografia foi realizada em 54 pacientes. A comparação entre o ultrassom transvaginal e a flebografia foi associada a 96.2% de sensibilidade e 100% de especificidade. Conclusões: OS AUTores chamam a atenção para a prevalência relativamente alta de varizes dos membros inferiores originadas na pélvis, sugerindo uma importante, embora subdiagnosticada, causa de varizes recorrentes.

ObjectiveThis clinical study evaluated prospectively adverse events immediately following ultrasound-guided foam sclerotherapy (UGFS) for the treatment of lower extremity venous valvular insufficiency. Incidence of side effects associated with carbon dioxide (CO2) foam was compared with a historical control using air-based foam. The literature on the subject was reviewed.MethodsVital signs were monitored during and immediately after UGFS, and adverse events were recorded for 24 hours following the procedure. The air-based foam group had 49 patients: 44 women and 5 men. The CO2-based foam group had 128 patients: 115 women and 13 men. CEAP class was C2EpAsPr, describing varicose veins, primary etiology, and saphenous reflux. UGFS followed thermal ablation of the great saphenous vein. Foam was prepared using the three-way tap technique to mix gas with 1% polidocanol in a 4:1 ratio. Segments of the great and small saphenous veins and their tributaries were treated with UGFS. Foam volumes injected were 27 ± 10 (SD) (6-46 range) and 25 ± 12 (6-57 range) mL for air- and CO2-based foams respectively (P = .39). Incidence of adverse events was compared by χ2 statistics. Vital signs were compared by paired t test.ResultsDuring the procedure, the average heart rate decreased by less than 5 bpm for both groups (P < .001), and blood pressure decreased by less than 3 mm Hg in the CO2 group (P < .02). Respiratory rate, electrocardiogram, and pulse oxymetry did not change significantly in both air- and CO2-foam series (P > .05). Visual disturbances were experienced by 3.1% (4/128) and 8.2% (4/49) patients in the CO2 and air groups respectively (P = .15). Respiratory difficulties or circumoral paresthesia each occurred in 0.8% (n = 1) of the CO2 patients. Incidence of chest tightness (3.1% vs 18%), dry cough (1.6% vs 16%), or dizziness (3.1% vs 12%) were significantly lower in the CO2 vs air groups (P < .02). Nausea occurred in 2% and 4% of the CO2 and air-based foam groups (P = .53). Overall, the proportion of patients describing side effects decreased from 39% (19/49) to 11% (14/128) as CO2 replaced air for foam preparation (P < .001). Similar findings were described in the literature of air-based foam but data on the use of physiological gas were rare.ConclusionsSide effects decreased significantly if CO2 rather than air was employed to make the sclerosing foam for chemical ablation of superficial veins of the lower extremity.

Purpose: We observed that ultrasound examinations for deep venous thrombosis (DVT) were more frequently requested for women than for men in our vascular laboratory serving a general outpatient population and referral 774-bed hospital. Because existing literature presents conflicting information about sex differences in occurrence of DVT, we investigated correlation in our population with positive ultrasound study results and risk factors for DVT. Methods: In 13 months, 2055 ultrasound examinations for DVT were requested. Of these, 300 patients (15%) were categorized in four subgroups: 75 ultrasonography-negative men, 75 ultrasonography-negative women, 75 ultrasonography (DVT) – positive men, and 75 ultrasonography (DVT) - positive women for risk factor analysis. Results: Women comprised 64% (1311 of 2055) and men 36% (744 of 2055) of ultrasound examinations requested, but men had significantly higher incidence of DVT-positive ultrasonography results (101 of 744 [14%]) compared with women (118 of 1311 [9%]) ( p = 0.002 by chi-square testing). There were no significant sex differences in conventional DVT risk factors and no difference in aggregate number of risk factors. The anatomic distribution of DVT was the same in men as in women. Among those having negative ultrasonography results, significantly more outpatient examinations were performed in women ( p = 0.018 by t testing). Conclusions: Gender bias exists in use of ultrasonography for diagnosis of DVT. The greater incidence of women undergoing venous ultrasonography is not explained by higher prevalence of DVT risk factors or of higher occurrence of positive ultrasound examination results. Further investigation is needed to determine whether these differences indicate underuse of ultrasonography in men or overuse in women. (J VASC SURG 1995;22:538-42.)

Objective As an emerging endovascular alternative to ligation and stripping of the incompetent greater saphenous vein (GSV), radiofrequency ablation was monitored with ultrasound scaning to evaluate anatomic results. Neovascularization and inflammation are potential consequences that lead to the appearance of small vessels. The natural history of the below-knee untreated GSV segment may be important in our understanding of ongoing chronic venous disease. An ultrasound follow-up study was conducted to determine the prevalence of small vessel networks, defined as veins and arteries less than 2 mm in diameter, adjacent to the saphenofemoral junction (SFJ); prevalence of small vessel networks adjacent to the treated GSV in the thigh; and fate of the below-knee untreated GSV distal to the ablated segment. Methods One hundred six extremities with radiofrequency ablation of the GSV for treatment of superficial venous insufficiency were followed up with high-resolution ultrasound imaging 4 to 25 months (median, 9 months) after the procedure. Ninety-three limbs had concomitant ligation and division of the SFJ and its tributaries, and 13 limbs underwent radiofrequency ablation without SFJ ligation. Ultrasound was used to evaluate patients for small vessel networks, and concomitant findings of small vessel networks and recanalization at the SFJ and adjacent to the treated GSV. The status of the below-knee segment of untreated GSV was evaluated for patency and reflux. Data analysis compared the findings in the ligation group with those in the no-ligation group, with the χ 2 test and Fisher exact test. Results We found small vessel networks in 65% (n = 69) of extremities: 15% (n = 16) at the SFJ only, 26% (n = 28) in the thigh only, and 24% (n = 25) at both the SFJ and thigh, resulting in a small vessel network prevalence of 39% (n = 41) at the SJF and 50% (n = 53) in the thigh. The prevalence of small vessel networks at the SFJ was significantly less after radiofrequency ablation with SFJ ligation (34%, 32 of 93) than after radiofrequency ablation without ligation (69%, 9 of 13; P = .035). Small vessel networks and GSV recanalization at the SFJ was more common in patients undergoing radiofrequency ablation without ligation (46%, 6 of 13) than after radiofrequency ablation with ligation (14%, 13 of 93; P = .014). The prevalence of small vessel networks in the thigh was not affected by SFJ ligation. The below-knee GSV was patent in 79% (84 of 106), and 58% (61 of 106) demonstrated reflux, a decrease from the pre–radiofrequency ablation rate of 71% (75 of 106), possibly because thrombosis extended distally beyond the ablated segment in 16% (17 of 106) of the legs. Conclusions Small vessel networks were detected adjacent to or in connection with most of the radiofrequency ablation–treated GSVs. SFJ ligation was associated with fewer small vessel networks and proximal GSV recanalization. Most below-knee untreated GSV segments remained patent, and most exhibited reflux.

Purpose: Tumor necrosis factor (TNF), interleukin 1 (IL-1), and matrix metalloproteases have been noted to be elevated in human abdominal aortic aneurysms (AAAs) as compared with normal and occlusive aortic disease. Because TNF and IL-1 have been shown to cause release of proteases that weaken the aortic matrix, it has been suggested that these cytokines may play a central role in the aortic dilatation process. To substantiate this hypothesis, we investigated the effects of TNF and IL-1 antagonists, tumor necrosis factor binding protein (TNF-BP) and interleukin-1 receptor antagonist (IL-1RA), on the development of AAAs in a well-described rat model. Methods: Isolated segments of infrarenal aorta of 16 rats were perfused with porcine elastase. In the treated group, eight rats were given intravenous TNF-BP prior to elastase perfusion, at 48 hours and at 96 hours. In the control group, eight rats were given only intravenous vehicle at the same time intervals. Isolated segments of infrarenal aorta of an additional 16 rats were perfused with porcine elastase in a similar fashion. In the treated group, eight rats were given intraperitoneal IL-1RA prior to celiotomy and every eight hours. In the control group, eight rats were given only intraperitoneal vehicle at the same time intervals. On the sixth postoperative day, all rats underwent celiotomy and measurement of the infrarenal aortic diameter with a micrometer while the animal was alive. Aortic specimens were collected on day six for hematoxylin and eosin staining, trichrome staining, and gel polyacrylamide gel electophoresis (PAGE) zymography. Results: TNF-BP was completely able to block post elastase dilation, whereas IL-1Ra seemed to have no effect. Hematoxylin and eosin staining and trichrome staining revealed that animals treated with TNF-BP had less of an inflammatory response and preservation of the elastin and smooth muscles in the media of the aortic wall as compared with animals treated with IL-1RA or vehicle. Zymography was not able to detect significant protease activity in the aortic wall of any of the rats at six days. Conclusion: TNF-BP, but not IL-1RA, may inhibit the development of AAAs in this model. (J Vasc Surg 1998;28:522-6.)

Successful long-term limb salvage using cephalic vein bypass grafts was attained in 70 limbs of 67 patients over the past 11 years. The saphenous vein was absent in 76% and inadequate in 24% of the cases. Revascularization for limb salvage was carried out in 83%. Ninety per cent of the grafts were extended to the infrageniculate level while 56% were to a tibial vessel. Patency rates at 1, 3, and 5 years were 85%, 72%, and 68%, respectively. Limb salvage rate was 85% at 5 years and thereafter. There were no operative deaths or upper extremity morbidity. The 5-year survival rate was 50%. The results obtained with cephalic vein were comparable to those reported using saphenous vein but superior to those reported for nonautogenous bypass grafts.