Search

Competing Interests: J.-L. Gillet déclare avoir été pris en charge, à l’occasion de déplacements pour congrès, par Kreussler Pharma.

Objective: The negative predictive value of D-dimer (DD) assay in patients with venous thromboembolic disease is well established for deep vein thrombosis and pulmonary embolism. Little is known about the value of DD assay in patients with superficial thrombophlebitis (ST). The purpose of this study was to assess the value of DD assay in patients with ST of the lower limb., Method: The study group was composed of 100 consecutive patients, irrespective of age. Patients with clinical manifestations suggestive of ST of the lower limbs with positive duplex color Doppler evidence confirming the diagnosis and DD assay results (Vidas D-Dimer Exclusion) within 24 hours were included in the study. Patients with thrombosis in another site in addition to the superficial vein of the lower limb, those taking anticoagulants for more than 48 hours, and those with a condition known to potentially elevate DD levels were excluded. The volume of the thrombus was determined echographically and reported as mean diameter and length., Results: Sixty-two women and 38 men were included. Mean age (+/- 5) was 58 years +/- 13.48 (range 18-90; median: 57). The ST involved the Great saphenous (n=74), the small saphenous (n=11) or another vein (n=15). Mean thrombus volume was 4453 mm(3) +/- 7101 (range 94-38484; median: 1751). Mean DD level was 829 ng/ml +/- 516.72 (range 100-2567; median: 715.5). DD assay was negative (<500 ng/ml) in 32 patients (32%) and positive in 68 (68%). For these three items, there was no significant difference between ST with and without varicose veins. DD assay was always positive (>or=500 ng/ml) in all patients aged over 70 years (n=22). In patients aged less than 70 years (n=78), DD assay was positive in 46 (59%) and negative in 32 (41%). DD level was positively correlated with thrombus volume in patients aged less than 70 years (P<0.0001). ROC analysis, sensitivity as a function of specificity by thrombus volume for the entire population, determined the usefulness of a negative DD assay. Considering the critical threshold at 5914 mm(3), sensitivity was 1.0 (95CI 0.89-1.0), with 0.29 specificity (95CI 0.19-0.42), 1.00 negative predictive value and 0.75 positive predictive value. However, the thrombus volume was less than this threshold value in three of the nine cases of ST with extension to the terminal portion of the saphenous., Conclusion: A positive DD assay was observed in 68% of patients with ST, with no significant difference with or without varicose veins. The test was positive in all patients aged over 70 years and in 59% of those aged under 70 years. There was a correlation between DD level and thrombus volume, yielding a threshold volume (5914 m(3)) above which all DD tests were positive. Nevertheless, this threshold volume was too great to include all ST extending to the terminal portion of the saphenous. Measurement of DD level is thus not contributive to the diagnosis of ST.

Patients who undergo surgery involving the groin and the popliteal fossa often develop recurrent varices which require careful management. Several surveys using various classification systems have estimated the prevalence of recurrent varices after groin and popliteal surgery. Patients may seek medical care for various reasons: unsightly recurrent varicose veins, vein-related symptoms, appearance of cutaneous or subcutaneous changes, concerns about the health risk related to their veins or limitation of activity. Recurrent varices may also be found at routine follow-up examinations. An analysis of recurrence at this location reveals three main mechanisms: incomplete resection of the saphenofemoral or saphenopopliteal junctions in patients with an initially incompetent terminal valve. The persisting reflux feeds the tributaries connected at the saphenous stump; the second mechanism is related to neovascularisation that reconnects the deep venous system with the superficial network; the neo-veins are valveless. This phenomenon appears to be more frequent when the resection of the saphenous vein ending has been complete; the third mechanism is due to a tactical error; the refluxive pelvic veins that had not been diagnosed feed the varices. Duplex scanning identifies the different possible mechanisms and provides anatomical and hemodynamic data. Interventional treatment methods after varices recurrence are redosurgery, sclerotherapy and pelvic vein embolization when they are at issue. All these methods are described in details. Results provided by these treatments are analysed. Unfortunately no randomized control study enables grade A or B recommendations. Personally we suggest that ultrasound guided foam sclerotherapy should be the first-line treatment except when duplex scanning reveals an intact incompetent saphenous stump at the saphenofemoral junction or/and saphenopopliteal junction with a massive reflux filling the varicose network.

Unlabelled: Recent publications allow better understanding of superficial thrombophlebitis (ST) of the lower limb veins. However ST occurring in non varicose veins (NVV) and those occurring in varicose veins (VV) are seldom distinguished in literature., Aims of the Study: 1) To estimate the potential gravity of ST occurring in NVV by putting a figure on the frequency of associated deep venous thrombosis (DVT) and symptomatic pulmonary embolism (PE); 2) to identify some risk factors (thrombophilia, systemic disease, thromboembolic events); 3) to assess the different types of thromboembolic recurrent events after superficial thrombophlebitis (TRST) and identify the risk factors for recurrence., Material and Method: Forty-two cases of ST occurring in NVV were included consecutively and prospectively in this series; TRST possible risk factors were evaluated. Patients were assessed at 1 month and followed up to 3 years. Isolated ST was treated with low-molecular-weight heparin at prophylactic dosage from 15 to 21 days and with elastic compression., Results: 1) A DVT was combined in 12 cases (28.6%) located in the calf (n=9) or in the femoro-politeal axis (n=3). One symptomatic PE occurred confirmed by ventilation-perfusion lung scan; 2) The risk factor investigations identified a neoplasm in 2 patients (4.8%), a non neoplasic systemic disease in 4 (9.5%) and a thrombophilia in 20 patients. The most frequent thrombophilia was the heterozygous mutation of coagulation factor V (Leiden); 3) All patients were assessed at 1 month with a clinical examination and Duplex Scanning. We did not identify either new DTV, PE or extension of the previous DVT; 4) 17 TRST were identified in 13 patients. Three patients had 2 recurrences; one patient presented a TRST located at 2 different sites. In total 8 new ST and 9 DVT were identified., Discussion: The analysis of the literature shows that early complications or combinations (DVT and PE) occur with the same prevalence in NVV and VV groups. A risk factor was identified in 62% of patients in this series (thrombophilia was the most common) and TRST were statistically more frequent in this series than in groups of ST occurring in VV we had previously analyzed. A post-thrombotic syndrome and a DVT associated with the ST were identified as statistically significant risk factors for recurrence., Conclusion: ST occurring in NVV, although representing 5 to 10% of all ST, is seldom reported in the literature. Like ST occurring in VV, they have a potential gravity (associated DVT and PE). However these two diseases should be distinguished. A risk factor is more often identified and TRST are more frequent in the group of ST occurring in NVV. We advise active management of these thromboses including screening for a risk factor, the implementation of measures for preventing venous thrombosis recurrence and patient follow-up.

Objectives: Our objectives were first to estimate the potential gravity of superficial venous thrombosis (SVT) of the lower limbs by determining the frequency of associated deep venous thrombosis (DVT), pulmonary embolism (PE) and extensions of the junction or a perforating vein and second to identify factors of risk (neoplasia, thrombophilia, connective tissue disease, thromboembolic events)., Method: We conducted a prospective study in 100 cases of SVT in 88 patients with varicose veins (VV) and 12 patients without varicose veins (NVV)., Results: Superficial venous thrombosis was identified in 32 cases (32%): muscle vein in 23 (gastrocnemius, solesu), popliteo-femoro-iliac system in 5, and posterior tibial or fibular vein in 4. In 17 cases (17) the SVT extended to deep veins at distant localizations in 15 (15%). Pulmonary embolism was suspected clinically in 10 cases (10%) and confirmed in 3 (3%). An extension to the saphenous junction was observed in 17 cases (17%) and the thrombus migrated into a deep vein in 7. There were 6 cases of a unique extension to a perforating vein. Search for etiology was conducted in 86 cases: 64 were negative (74.4%), there was a neoplasia context in 5 (6%) and a hemostasis disorder in 17 (19.8%) including 6/12 (50%) in the NVV group and 11/74 (15%) in the VV group., Conclusion: Superficial venous thrombosis is often considered to be benign although severe situations can occur in patients with a hemostatis disorder. Consideration of these different factors (risk factors, presence of a deep venous thrombus or pulmonary embolism) should be helpful in determining the etiology and for a better choice of a therapeutic option (medical/surgical) depending on the different subpopulations identified.

Aims of the Study: Does preoperative Duplex Scan (DS) allow to determine anatomy of the ending of the short saphenous vein (SSV), gastrocnemius vein (GV) and reflux in popliteal vein (PV), SSV and GV. Postoperative DS was performed to detect deep vein thrombosis (DVT) and GV thrombosis., Material and Methods: From June 94 to November 95 one hundred and eighty lower limbs operated for SSV were included consecutively and prospectively. Mean age in these 154 patients was 52 yr (24-80) with a sex ratio 4F/1M. An anatomical classification was previously defined. Type A: separate termination of SSV and GV; Type B: common ostium of SSV and GV in the popliteal vein; Type C: common trunk of the SSV and GV; Type D: Others. Forty-eight limbs (26.10%) had ligation of GV: 21 (11.10%) for reflux and 27 (16%) for anatomical or surgical reasons. Ten type A with GV reflux (10/31 = 32%) were not treated. Eighty two patients (45%) received preventive low molecular weight heparin (LMWH) treatment including the 48 limbs whose GV were ligated., Results: Anatomical correlation between DS and surgery findings were calculated. Positive predictive values of DS in the different types were: A, 77%; B, 68%; C, 90%; D, 79%. That gave a global predictive value of 80%. Two limited DVT were identified in group D by postoperative DS (2/10 = 1.1%). These two patients had complete recanalization of PV without reflux. In the group of limbs which had ligation of GV we identified 37.5% of GV thrombosis. In the group without ligation of GV we found 3% of GV thrombosis., Conclusion: Duplex scanning appears to be the investigation of choice before surgery for superficial vein incompetence in the popliteal fossa. It is a reliable investigation to determine termination patterns of SSV and GV (80%). It brings to the surgeon essential information which helps in the management of surgical procedure and particularly to ligation of gastrocnemius veins. But at this time there is no consensus on this point. The occurrence of DVT after SSV surgery including GV ligation was very low. Two questions remain: is anticoagulation necessary in all patients or selective after surgery of the SSV? is Duplex Scan mandatory during postoperative monitoring? On the basis of this study, one recommendation can be made: A routine postoperative DS is necessary after ligation of the GV or when the dissection of the popliteal fossa has been extensive (Type D).