Search

Ultrasonographic investigation of the various forms of chronic venous insufficiency has substantial advantages compared to diagnosis with the competing phlebogram, particularly preoperatively. Important details such as side branches in the region of the groin, course variations of the small saphenous vein and insufficiency of the perforators in the lower leg are sometimes missed in the antegrade phlebogram. However, it is absolutely necessary to take these into consideration in order to attain a substained good result of surgery. With adequate qualification of the investigator and using all ultrasound techniques, diagnosis by sonography is better than by means of antegrade phlebogram. There are clear specifications for the documentation. With regard to costs and time required, ultrasonographic investigation of chronic venous insufficiency is superior to the antegrade phlebogram and can be repeated at any time.

Reflux in deep veins is an important pathophysiological factor of post-thrombotic syndrome which can be demonstrated by colour-coded duplexsonography. This study investigates the effect of different compression therapies on the reflux velocity in deep veins in patients with a post-thrombotic syndrome.Sixty patients with a post-thrombotic syndrome-confirmed by phlebography, in the deep veins of the calf and the thigh were investigated in two groups: In group A, 30 patients (mean age 58 +/- 10 years) received compression stockings (calf compression class II and III, thigh compression class II) and in group B 30 patients (mean age 58 +/- 14 years) received a Sigg short traction bandage of the calf. The velocity at the time of the greatest reflux in the popliteal vein was determined as reflux parameter with the colour-coded duplex sonography using a cuff applied at the calf. All patients stood upright and were measured with and without different kinds of compression therapies. The reflux velocities were graded as low, moderate and high.A significant decrease of the reflux velocity by about more than 45% with compression therapy was found in both groups. The decrease of the refluxes in group A (mean 47.9%) did not differ significantly from the decrease of refluxes in group B (mean 55.8%). The greatest decrease of the reflux velocity under compression therapy was found in high-grade refluxes in both groups.A significant decrease of the reflux velocity in post-thrombotic syndrome can be readily demonstrated with different kinds of compression stockings as well as with bandages by means of colour-coded duplex sonography.

In Analogie zu den in Kap. 8 des Bereichs I dieses Lehrbuches behandelten Diagnose- und Therapiestrategien arterieller Durchblutungsstorungen soll in diesem Kapitel dargelegt werden, wie die in den Kapiteln 31–34 beschriebenen Untersuchungs- und Therapieverfahren bei Venenkranken rationell und im Sinne „stufenformiger“ Entscheidungen eingesetzt werden. Dabei werden hier nur chronische Venenkrankheiten, nicht aber die akute tiefe Venenthrombose berucksichtigt, deren Stufendiagnostik und Stufentherapie in 38.6.3 und 38.7.5 behandelt werden.

Der Begriff „chronische venose Insuffizienz“ (CVI) wird i. allg. klinisch aufgefast und bedeutet, das aufgrund einer venosen Ruckflusstorung aus Armen oder (meist) Beinen unabhangig vom Ausmas subjektiver Beschwerden objektivierbare klinische Zeichen entstehen, die letztlich Folge eines dauerhaft erhohten Drucks in den kleinen Venen und Venolen der abhangigen Gewebebereiche (Muskulatur, Haut) sind (Vin 1992). Die „chronische venose Insuffiziens“ ist vom Begriff der „Veneninsuffizienz“ zu unterscheiden, der haufig synonym verwendet wird. Wenn der Begriff Veneninsuffizienz uberhaupt verwendet werden will, so bedeutet dieser allenfalls ein mehr oder weniger umschriebenes funktionelles Defizit eines anatomisch beschreibbaren Venensegmentes oder Venensystems (z.B. Klappeninsuffizienz, obliterierte Venen oder Ahnliches), nicht jedoch die klinischen Folgen dieser Defizite, die das klinische Bild der CVI ausmachen.

Reflux in deep veins is accepted as the most important pathophysiologic phenomenon in postthrombotic syndrome. The data proved by colour coded duplex sonography are demonstrated in this summary. As the different methods to provoke reflux yet are not examined we present our own results. A velocity of more than 10 cm/sec. at the time of the greatest reflux, a duration of reflux of more than 2 seconds and the lack of the valve signal are the best criteria to detect and quantify a postthrombotic syndromE by colour coded duplex sonography. Using Valsalva's maneuver, calf compression and cuff compression test to provoke reflux, the cuff compression technique proved to be the best one.

Comparison of colour-coded Doppler sonography, CW-Doppler and real time sonography in the diagnostics of the postthrombotic syndrome.Colour-coded Doppler sonography, CW-Doppler and real time sonography were studied in 40 legs with postthrombotic syndrome, confirmed by phlebography. In a further step deep veins of patients with primary varicosis (n = 40) and a group of normal veins (n = 40) where compared with the postthrombotic group (n = 40).The sensitivity of CW-Doppler was 71.2% and that of real time sonography 67.5%, their specificity 92.3% and 92.2%, respectively, while colour-coded Doppler sonography had a sensitivity of 90.9% and a specificity of 88.9%. In addition, colour-coded Doppler sonography in combination with measurement of the peak velocity of venous reflux in deep veins had the highest sensitivity with 92.8% and specificity with 95.4% of all ultrasound methods tested. By means of colour-coded Doppler sonography together with measurement of the peak velocity of venous reflux, healthy persons and patients with varicosis could be distinguished with high significance (p0.003) by a peak velocity of venous reflux of more than 10 cm/s.In comparison to real time sonography and CW-Doppler, quantitative analysis of reflux in the deep veins by means of colour-coded Doppler sonography is the most valid ultrasound method in the diagnosis of postthrombotic syndrome.

Until now, the diagnosis of the postthrombotic syndrome is based upon venography. This study compares the diagnostic value of the CW-Doppler with the sonographic signs in the deep venous system observed in B-mode sonography and with the quantitative measurement of venous reflux by color Doppler sonography. 84 venous sections of 21 patients with phlebographically diagnosed PTS and substantial clinical signs were examined. CW- Doppler and B-mode sonography did not show significant differences compared to phlebographic findings. Color doppler sonography, however, showed signs which significantly went beyond those seen in venography.

Doppler ultrasound has been a useful, noninvasive technique in the diagnosis of deep venous thrombosis. Until now, primary or secondary varicosities could only be clarified through phlebography or strain-gauge plethysmography. The aim of our study was to assess the flow time in 28 patients with primary varicose veins and postthrombotic syndrome using Doppler ultrasound. The Wilcoxon-Test was used for statistical reviewing in the second test, revealing a significant difference between both groups. The confidence intervals did not overlap.

A simple score for mobilisation of patients with deep venous thrombosis of the leg is proposed. By this score the significantly earlier mobilisation of patients with deep venous thrombosis is possible without risk.

When compared with the phlebogram, the duplex examination proves to be a suitable procedure for diagnosing the incompetence of the junction of the long saphenous vein and of the short saphenous vein. The sensitivity and the specificity of the duplex at the junction of the long saphenous vein amounts to 0.96 and 0.75 respectively and at the junction of the short saphenous vein they are 0.90 and 0.67 respectively.

The influence of contrast medium (20 ml Meglumine Diatrizoate 65%; Angiografin) on peripheral circulation was studied after injection into the vena saphena magna in 12 patients (mean age 40.5 years) with markedly varicose veins. Pneumatic segment-plethysmography and "mercury-in-rubber" strain-gauge-plethysmography were used to investigate local and systemic effects of contrast medium on intravascular basic volume and pressure-dependent venous capacity. Heart rate was controlled by Ecg-monitoring, venous blood pressure by means of a Schwarzer pressure transducer, and peripheral blood flow by means of pneumatic segment-plethysmography. In addition peripheral vascular resistance was calculated. Local effect of contrast medium on large veins was a small insignificant increase (2.2%) of venous capacity. However, there was a significant increase of additional 10% after recirculation (2 P less than 0.01). Intravascular basic volume showed a significant increase as well (2 P less than 0.01). In addition the calculated increase of total intravascular volume--represented by intravascular basic volume plus venous capacity--was 16.3% related to an intravenous pressure of 70 mm Hg. According to these findings, 20 ml contrast medium enlarges the blood volume dumping into the legs with postural changes by approximately 270 ml. Arterial inflow increased significantly (2P less than 0.01) by 40% after contrast injection, whereas mean arterial blood pressure decreased simultaneously. Consequently a reduction of peripheral vascular resistance of 32% was calculated. The neglectable local effect of contrast medium on pressure-dependent venous capacity is probably due to the markedly reduced distensibility of varicose veins. In contrast a striking effect of contrast medium is observed after recirculation, which is felt to be due to a general vasodilatation of capillary vessels and pre- and postcapillary resistance vessels.

In chronic venous insufficiency, phlebodynamometry by invasive venous-pressure measurement demonstrates a reduced pressure drop and an accelerated pressure rise, resulting from the action of the ankle-joint-calf muscle "pump". On the other hand, light-reflexion rheography and photoplethysmography can measure only the duration of the refilling period. Simultaneous measurements were made on 47 legs after phlebography (normal: 8; side-arm varicosities: 17; long-saphenous insufficiency: 15; postthrombotic syndrome: 7). Refilling time by photoplethysmography correlated better with that measured invasively than by light-reflexion rheography. Refilling half-time cannot be measured accurately with either noninvasive method. Sclerosing treatment of single side-branch varicosities in ten legs demonstrated that merely measuring refilling time (invasively or noninvasively) was not sufficient, because this value did not indicate any improvement in haemodynamics even after successful treatment.

Bei allen Fortschritten der letzten Jahre, die unter Verwendung von jodmarkiertem Fibrinogen in der venosen Thrombosediagnostik erzielt wurden, sind manche Beobachtungen und Einwande gegen diese Methode ubergangen worden.

The influence of contrast medium (20 ml Meglumine Diatrizoate 65%; Angiografin) on peripheral circulation was studied after injection into the vena saphena magna in 12 patients (mean age 40.5 years) with markedly varicose veins. Pneumatic segment-plethysmography and "mercury-in-rubber" strain-gauge-plethysmography were used to investigate local and systemic effects of contrast medium on intravascular basic volume and pressure-dependent venous capacity. Heart rate was controlled by Ecg-monitoring, venous blood pressure by means of a Schwarzer pressure transducer, and peripheral blood flow by means of pneumatic segment-plethysmography. In addition peripheral vascular resistance was calculated. Local effect of contrast medium on large veins was a small insignificant increase (2.2%) of venous capacity. However, there was a significant increase of additional 10% after recirculation (2 P less than 0.01). Intravascular basic volume showed a significant increase as well (2 P less than 0.01). In addition the calculated increase of total intravascular volume--represented by intravascular basic volume plus venous capacity--was 16.3% related to an intravenous pressure of 70 mm Hg. According to these findings, 20 ml contrast medium enlarges the blood volume dumping into the legs with postural changes by approximately 270 ml. Arterial inflow increased significantly (2P less than 0.01) by 40% after contrast injection, whereas mean arterial blood pressure decreased simultaneously. Consequently a reduction of peripheral vascular resistance of 32% was calculated. The neglectable local effect of contrast medium on pressure-dependent venous capacity is probably due to the markedly reduced distensibility of varicose veins. In contrast a striking effect of contrast medium is observed after recirculation, which is felt to be due to a general vasodilatation of capillary vessels and pre- and postcapillary resistance vessels.

The quantitative measurement of plasma fibrin monomeres in three patients with Arwin-treatment by affinity chromatography on agarose fixed fibrinogen and the "tüpfel method" demonstrated high specifity and sensitivity. Plasmafibrinmonomer concentration clearly differs both before and during treatment from results reported in the literature. The method results in a better control of dangerous situation, especially with additional application of fibrinolytic agents.

Using a multi-wire surface electrode, oxygen pressure fields were determined in leg ulcers of 11 patients with chronic venous insufficiency (cvi). In three of them, cvi was combined with arterial occlusive disease. The histograms of all patients with very low PO2 values revealed microcirculatory disturbances of the ulcer tissue. The influence of leg position is reflected in the histograms. Patients with cvi showed higher PO2 values when the leg was raised in comparison with when it was in the hanging position. The patients with mixed ulcerations showed a significant increase in tissue PO2 when the leg was in the hanging position, which shows the importance of arterial perfusion pressure. After a compression bandage had been applied to the legs with cvi, the tissue oxygen pressure of the ulcers increased markedly, probably as a result of diminished blood stasis. These results can be explained either by a rarefaction of capillaries in the ulcer tissue or by fibrin diffusion barriers around the capillaries. The changes in the histograms after bandaging are thought to be caused by an improvement in venous circulation.

Results of Doppler sonography and angiography were compared in 100 consecutive patients with ischaemia in the area of carotid arterial supply. In 15 there were important differences. Three Doppler "occlusions" were angiographically demonstrated to be carotid arterial stenoses; significant additional information was provided by angiography in two patients with stenoses at the origin of the internal carotid artery, while in ten--despite unremarkable Doppler findings--angiography revealed disease in the carotids.

Morphometric investigations into the perforating veins in cases of primary varicosities have revealed typical, so far unrecognized, features of insufficiency. A significant difference was found in the diameters of central and peripheral parts of the vein amounting to a ratio of 1.5:1 with single, and 1.8:1 with paired incompetent perforators. These perforators therefore act in producing a jet. The pathophysiological and diagnostic significance of this jet phenomenon is discussed. Variations in the pattern and frequency of incompetent perforators were found between the medial and lateral aspects of the calf. Evidence concerning the mode of incompetent perforators is discussed.

The development of leg ulcers is attributed to disturbed skin microcirculation, which is said to be the result of an increase in capillary pressure with the leaking of blood components through the capillary wall and the formation of a specific microedema [5]. Transcutaneous oxygen pressure measurements in the vicinity of ulcers yielded low values in both venous and arterial ulcers [1]. This is explained by a rarefication of capillaries [8]. In contrast, patients with liposclerosis or venous ulcerations show a marked proliferation of capillaries in the subcutaneous tissue [3]. Around the capillaries, fibrin walls are found, which act as diffusion barriers for oxygen [2]. Local hyperemia is observed after positron emission tomography and measurements of the blood flow in the skin using the laser-Doppler method [7, 10]. We have determined the tissue oxygen pressure in leg ulcers.

A method for preparation of autologous 131J-tagged human fibrinogen is demonstrated. In vitro the preparation is characterized by content of fibrinogen, protein, plasminogen, clottability and molecular weight. Total plasma radioactivity, specific radioactivity, non-protein-bound radioactivity, biologic half-life and the local activity at the thrombus define the properties in vivo. With the above criteria autologous 131-J-tagged human fibrinogen was shown to be useful for early diagnosis of venous thrombosis.

The ascending phlebography of the lower extremity gives no functional evaluation of venous blood-flow under the activity of the venous muscular pump. A newly developed semiquantitative method of functional phlebography by videodensitometry extends the measurability of vein dynamic. The influence of compression hoses on venous flow dynamics associated with varicose veins is examined by this method.

After intravaricose injection of 3% ethoxysclerol a slight hyperfibrinolysis appears in the blood of a cubital vein. This is too weak to judge of the reality of the sclerosis. On the other hand, a very marked fibrinolysis is not seen after injection of ethoxysclerol. Fibrinogen labelled with iodine 131 however permits an exact control of what is happening at the site of the sclerosant injection. The reaction develops slowly, reaching its maximum not until 5 days after the injection of sclerosant. There is therefore no need to fear a sudden thrombosis which might be difficult to control.