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Incompetent communicating or perforating veins are often responsible for recurrent varicose veins with skin changes at the lower leg, especially in the postthrombotic syndrome. Subcutaneous and subfascial surgical explorations carry a 35% complication rate. We used a new endoscopic technique to locate and ligate communicating veins with the objective to decrease this complication rate. Through a short skin incision on the anteromedial side of the proximal 1/3 of the lower leg the fascia is incised over 2 cm and the subfascial space opened by finger dissection. A mediastinoscope (length 18 cm; diameter 12 mm) is inserted and pushed down beneath the fascia to the level of the malleolus. Under direct vision the communicating veins crossing this space are located and ligated with haemoclips. In 48 patients, 15 male and 33 female, with a mean age of 53 (22-73) years, 54 legs were treated: 40 legs showed recurrent varicose veins, due to incompetent communicating veins with severe skin changes and ulcers, and 14 had primary varicosis. All patients complained of fatigue and pain. In 49 legs (44 patients) relief of preoperative complaints was obtained and in 5 (4 patients) there was no change. Two indurated wounds and 1 dehiscent wound were treated conservatively. One patient, operated on both legs, developed a severe subfascial infection on both sides necessitating a reintervention. The advantages of the subfascial endoscopic technique, a fast operative procedure, fewer postoperative wound infections (9.3%), a good cosmetic effect, and a low (2.5% after 3.8 years) recurrent ulcer rate make it a valuable new method for treating incompetent communicating veins.

In vitro and in vivo studies revealed significantly better haemodynamic properties for a newly designed axillo-bifemoral bypass graft, with a flowsplitter at the bifurcation. In order to analyse the clinical relevance of these improved haemodynamic properties a prospective randomised clinical trial was performed. The patency rates of two different axillo-bifemoral bypass grafts, differing only in the configuration of the bifurcation: one with a contralateral branch at an angle of 90 degrees and one with a flowsplitter, were analysed. In 19 centres, 117 patients were randomised, 59 receiving a prosthesis with a flowsplitter, and 58 a prosthesis with a 90 degrees bifurcation. Indications and risk factors were equally distributed in both groups. Final analysis after 3 years with a mean follow-up of 12 months (range 3-36 months) showed that the prosthesis with a flowsplitter had a significantly better patency rate after 2 years of 84% compared to the patency rate of the prosthesis with a 90 degrees-angled bifurcation of 38% (log-rank test, p less than 0.0001). These data were not significantly influenced by the indication for the operation, associated risk factors (e.g. diabetes mellitus, hypertension or myocardial infarction), outflow tract or anti-coagulant therapy. Other endpoints such as death and graft infection did not differ significantly.

The imaging quality of angiodynography (Quantum; Philips) in the ilio-femoral tract was compared with uniplanar angiography. One hundred ilio-femoral tracts were investigated with both translumbar conventional angiography and angiodynography. The ilio-femoral tract was divided into five parts; proximal and distal common iliac, proximal and distal external iliac and common femoral. Stenosis was scored from 0-24, 25-49, 50-74, 75-99 and 100% and the lengths of those of 25% or more were measured in centimeters. Because the thickness of the subcutaneous fat layer decreases the depth range (normally 11.5 cm) of the 5.0 MHz transducer it was also measured in centimetres. The results showed that a significantly larger number of vessels were not seen (especially the common iliac) with an increasing thickness of the subcutaneous fat. The results based on the real-time imaging quality alone of angiodynography showed a reasonable accuracy of 83.9% when detecting stenoses graded from 0-24, 25-49, 50-74, 75-99 up to 100%. The clinically more important discrimination between a haemodynamically important stenosis of more than 50% showed a sensitivity of 88% and specificity of 98% on visual information alone. By integrating the peak velocity measurements to the results, this sensitivity rose to 95% and the specificity became 99%. The correlation in length was within a range of 1 cm in 94% and within 1-2 cm in 6% of the stenoses. In conclusion, angiodynography is a reliable technique for investigating the ilio-femoral tract.