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Objectives: Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP), The aim was to obtain a consensus of international experts on the methodology to be used for assessment of anatomy of superficial and perforating veins in the lower limb by ultrasound imaging., Design: Consensus conference leading to a consensus document., Methods: The authors performed a systematic review of the published literature on duplex anatomy of the superficial and perforating veins of the lower limbs; afterwards they invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the authors and the experts (text and images) were made available to all participants via the UIP website. The authors prepared a draft document for discussion at the UIP Chapter meeting held in San Diego, USA in August 2003. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually all participants agreed the final version of the paper., Results: The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document provides a detailed methodology for complete ultrasound assessment of the anatomy of the superficial and perforating veins in the lower limbs., Conclusions: The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs venous system by duplex ultrasonography, with specific reference to the anatomy of the main superficial veins and perforators of the lower limbs in healthy and varicose subjects.

Objectives: Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP). The aim was to obtain a consensus of international experts on the methodology to be used for assessment of veins in the lower limbs by ultrasound imaging., Design: Consensus conference leading to a consensus document., Methods: The authors invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the experts were made available to all participants via the UIP website. The authors prepared a draft document for discussion at a UIP Chapter meeting held in San Diego, USA in August 2005. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually all participants agreed to the final version of the paper., Results: The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document suggests a methodology for complete assessment of the superficial and perforating veins of the lower limbs, including recommendations on reporting results and training of personnel involved in these investigations., Conclusions: The authors and a large group of experts have agreed to a methodology for the investigation of the lower limbs venous system by duplex ultrasonography.

Objectives: Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP), The aim was to obtain a consensus of international experts on the methodology to be used for assessment of anatomy of superficial and perforating veins in the lower limb by ultrasound imaging., Design: Consensus conference leading to a consensus document., Methods: The authors performed a systematic review of the published literature on duplex anatomy of the superficial and perforating veins of the lower limbs; afterwards they invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the authors and the experts (text and images) were made available to all participants via the UIP website. The authors prepared a draft document for discussion at the UIP Chapter meeting held in San Diego, USA in August 2003. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually, all participants agreed the final version of the paper., Results: The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document provides a detailed methodology for complete ultrasound assessment of the anatomy of the superficial and perforating veins in the lower limbs., Conclusions: The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs venous system by duplex ultrasonography, with specific reference to the anatomy of the main superficial veins and perforators of the lower limbs in healthy and varicose subjects.

Three surgeons performed 180 atherectomy procedures in 161 patients using the Transluminal Extraction Catheter in 144 and the Auth Rotablator in 36. The primary patency rate was 55% at 1 year and 46% at 2 years, and failure was caused by stenosis in 28 (15.6%) and occlusion in 61 (33.7%) limbs. Multivariate Cox regression analysis showed significantly better outcome if the indication was claudication, the lesion was short or there was associated stenting. Vascular laboratory surveillance was performed in 93 limbs in 83 patients. Cox regression analysis in this subgroup also showed a significant relationship between outcome and the maximum peak systolic velocity from a duplex scan at the last study performed. Receiver operating characteristics curves showed that a raised maximum peak systolic velocity best predicted late failure (sensitivity 84%, specificity 66% for > 200 cm/s; sensitivity 72%, specificity 84% for > 250 cm/s); the velocity ratio at the stenosis to that in the segment above or the resting ankle/brachial pressure index were less predictive. For 50 procedures studied in the vascular laboratory which remained successful to the end of the study, maximum peak systolic velocities were > 250 cm/s from the first postoperative study, suggesting residual stenosis in 6%, or increased to become > 250 cm/s by the last study, suggesting recurrent stenoses in 12%. For 43 procedures which were studied and later failed, velocities were > 250 cm/s from the first test in 26% or increased to > 250 cm/s by the last test before failure in 40%. Vascular laboratory surveillance helps to predict outcome after atherectomy. Failure may be a result of residual disease from the time of the procedure or from restenosis. The apparent high incidence of clinically manifest or developing stenoses raises doubts as to the benefit of atherectomy over balloon dilatation alone.

Purpose: Patterns of flow in superficial and deep veins and outward flow in medial calf perforators were studied by duplex ultrasonography scanning in 1653 lower limbs in 1114 consecutive patients. This study compares results in 776 limbs with primary uncomplicated varicose veins with those in 166 limbs with the complications of lipodermatosclerosis or past venous ulceration., Methods: Duplex scanning determined whether superficial and deep veins were occluded or showed reflux and whether outward flow occurred in medial calf perforators with calf muscle contraction., Results: Two proximal deep veins were occluded. When limbs with primary uncomplicated varicose veins, lipodermatosclerosis, or past ulceration were compared, superficial reflux alone was seen in 55%, 39%, and 38%, deep reflux alone was seen in 2%, 7%, and 8%, and combined superficial and deep reflux was seen in 18%, 34%, and 48%, respectively. Superficial reflux affected the long saphenous system alone in 58%, 57%, and 40%, the short saphenous system alone in 18%, 18%, and 26%, and both the long and short saphenous systems in 24%, 25%, and 34%, respectively. Limbs with ulceration more frequently showed superficial reflux (p < 0.05), and all limbs with complications more frequently showed short saphenous reflux (p < 0.05) and deep reflux (p < 0.01) specifically in the posterior tibial veins (p < 0.01). Outward flow was seen in medial calf perforators in 57%, 67%, and 66%, respectively; it occurred more frequently in all limbs with complications (p < 0.05). Isolated outward flow in perforators without superficial or deep reflux was seen in 10%, 10%, and 2%, respectively., Conclusions: Most limbs with complications had superficial reflux either alone or combined with deep reflux, and few had deep reflux alone. Reflux was more frequent in posterior tibial veins for limbs with complications compared with those with uncomplicated primary varicose veins. Outward flow in perforators was common in limbs with complications and with uncomplicated primary varicose veins, but isolated outward flow in perforators was uncommon. Treatment directed to the superficial veins alone may be sufficient for most patients with complications.

Purpose: To determine whether the Auth Rotablator device is suitable for endoluminal atherectomy for infrainguinal occlusive arterial disease., Methods: Two surgeons used the Auth Rotablator to perform 36 infrainguinal atherectomy procedures in 34 patients for severe intermittent claudication in 21, critical ischemia in 12, or graft stenosis in 3 limbs. There were 24 stenoses and 12 occlusions. Adjuvant balloon dilation was performed in 13 limbs and stenting in 5., Results: There was initial technical and anatomical success in 34 procedures (94%), and 24 technically successful procedures persisted at mean follow-up of 16.5 months, although 1 limb required major amputation. Three failures were due to stenosis requiring further intervention, and 9 were due to occlusion. Failure led to no further intervention in 2, amputation in 1, further endovascular intervention in 5, and open surgical reconstruction in 4 limbs. After further treatment, 29 limbs are patent with no return of symptoms, 3 are occluded, and 4 have required amputation, all for initial presentation with critical ischemia. Life-table analyses calculate primary and secondary patency rates of 61% and 67% and a clinical success rate of 56% at 12 months., Conclusions: Atherectomy using the Auth Rotablator provides acceptable results, but its role in comparison to other endovascular techniques is still to be defined.

Multivariate Cox regression analysis of patency rates for 750 consecutive femorodistal autogenous vein graftings for chronic lower limb ischemia showed that significant independent prognostic covariates were the type of graft (long saphenous or arm vein), presence of diabetes, and absence of a past history of myocardial ischemia. Analysis assumes that patients withdrawn with patent grafts due to death or loss to follow-up would have followed the same course as those who remain, and the degree to which this could distort results was studied. Patients who died with patent grafts were more likely to have had past myocardial ischemia and critical lower limb ischemia. Cox regression analysis for 600 operations after excluding patients who died with patent grafts then showed that significant independent covariates were the type of graft (long saphenous or arm vein) and indication (claudication or critical ischemia); then age, sex, hypertension, diabetes, myocardial ischemia, date of operation, surgeon, site of distal anastomosis, or first compared to repeat operations had no significant influence. Cox regression analysis helps determine which covariates influence graft patency rates, but results are affected by censored data, particularly from patients who die with patent grafts.

Extraperitoneal unilateral iliac artery bypass was used to treat chronic lower limb ischaemia in 105 patients (110 operations). This represented 20% of all operations for aorto-iliac disease. Unilateral iliac bypass was the preferred primary procedure for 99 operations, and was used to correct complications in one limb of a prior aortic bifurcation graft in the other 11. Ipsilateral femoropopliteal vein grafts were also performed in 45 legs (43%), prior to the iliac bypass in 18, as a synchronous operation in nine, and at a later date in 18 legs. This was a much higher proportion of combined operations than for patients by aortic bifurcation grafts (12%). Only 5 patients later required further proximal surgery, one for a blocked graft and four for contralateral iliac disease. The cumulative patency rate in surviving patients was 91% at 3 years. For the claudicants and for iliofemoral bypass operations, only one graft occluded, within 5 years, and no grafts occluded for operations where the superficial femoral artery was patent. The cumulative patency rates at 3 years were 85% for patients with critical ischaemia, 82% for ilioprofunda bypass operations, and 88% for operations where the superficial femoral artery was occluded. The cumulative foot-salvage rate in surviving patients initially treated for critical ischaemia was 77% at 3 years. The cumulative survival rate was 90% at 3 years. Extraperitoneal unilateral iliac bypass is now preferred as the primary operation for patients with apparent unilateral iliac disease causing severe ischaemia, if balloon dilatation is not appropriate or has failed.

Ischaemic rest pain or tissue necrosis in the foot requires arterial reconstruction or lumbar sympathectomy if major amputation is to be avoided. Arterial reconstruction is preferred but if it is not possible, lumbar sympathectomy frequently is adequate. Conservative treatment is rarely successful. Arterial reconstruction is a relatively safe procedure, even in the elderly. The long-term survival rates are reasonably good, though appreciably less than for the general community. Many amputees have a short life expectancy and do not regain independence.

A 45-year-old man developed severe leg ischaemia following anterior resection for rectal carcinoma. A previously unrecognized infrarenal aortic occlusion was also present. Division of important collateral arterial pathways during the anterior resection was the cause of ischaemia which contributed to the patient's death. Patients having rectal or colonic resection should be carefully assessed for aortoiliac occlusive disease. Extra-anatomical arterial reconstruction before the bowel resection would avoid this complication.

Over a 10-year period, 411 patients with atherosclerotic major artery disease causing severe ischaemia of the legs were treated by surgery. Their survival rate, assessed by the life table method, was 80 per cent at 1 year and 50 per cent at 5 years. Early and late survival rates were significantly worse in elderly patients, and in patients with extensive gangrene. Late survival rates were significantly worse in diabetics, and in patients with clinical myocardial ischaemia. Patients treated by arterial reconstruction showed a better survival rate than those treated by sympathectomy or amputation, though the latter groups contained more poor risk patients. Survival rates were not influenced by the technique of reconstruction.