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20.1 Long-term clinical follow-up of venous thrombolysis
0800-1200
Thusday, September 25, 1997
W&on ZO-V&m43 Co-Chairmen:E. Ascher, K.G. Bwnand Mountbatton Room 20.1 Long-term Clinical Follow-up of Venous Thrombol ysis P.E. THORPE, X.X. ZHAN and P.S. DOVGAN, Omana, Nebraska, USA Obje&ve: To assess long-term clinical results of aggressive thrombolysis for lower extremity deep venous thrombosis. Materials aRd M&o&: Ambulatory patients, with deep vein thrombosis (DVT) were evaluated for thrombolysis. Multisegmental thrombosis was treated in 43 patients (48 limbs, six IVC) with catheter and/or flow directed urokinase and heparin between 1988 and 1996. Clinical presentation was acute ( < 14days) in 63% and chronic (> 14 days) in 37%. While 30% had isolated acute venous occlusion, 70% had acute occlusion and chronic changes by phlebography. Oral anticoagulation was established before discharge and continued for at least 6 months. Baseline duplex and/or phlebography were compared to completion studies by an independent evaluator. Long-term follow-up was documented by duplex and physical examinations, a blinded telephone interview and results compared to anticoagulant treated patients. Rest&s: Delivery of urokinase was achieved in all patients; Six major procedure-related complications occurred including one death c 30 days. Early clinical success was 46/48 (96%). Five limbs were lost to follow-up, due to death (four) and arterial insufficiency (one). In total, 32145 (71%) limbs were followed > I2 months with a mean follow-up of 3.5 months range (6-92). No recurrent DVT occurred in 40/45 (90%). Longterm assisted clinical success was 43/45 (96%). Concfusiorcs: Patients presenting with acute DVT often have chronic venous pathology. Long-term results after thrombolytic therapy show a decreased incidence of recurrent thrombosis and chronic venous insufficiency compared to anticoagulant treated patients. Post thrombotic pain and edema is less severe especially in patients treated for an initial acute thrombosis. Thrombolysis appears to lessen the degree of disability associated with chronic/recurrent DVT.
20.2 Calf Perforating Veins; the Relationship Between Number, Size and Flow Patterns and the Haemudynarnit and Clinical Severity of Chronic Venous Ens&iciency UI! STUART, A.W BRADBUEE: D. ADAM, P. ALLAN and C.V. RUCKLEY, Edinburgh, UK Aim: To determine the relationship between severity of venous disease and the diameter, number and flow-patterns perforating veins.
CARDIOVASCULAR SURGERY SEPTEMBER 1997
of calf
Patients: Group (Gp) I, 31 limbs with no clinical or duplex evidence of venous disease; Gp II, 69 limbs with uncomplicated varicose veins only and Gp III, 61 limbs with complicated chronic venous insufficiency (22 lipodermatosclerosis (LDS) only and 39 with an open or healed ulcer). Methock Colour-flow duplex scanning to determine sites of reflux and photoplethysmography to determine the half venous refilling times (VRT SO). Results: Increasing clinical severity of venous disease was associated with a decrease in VRT 50 values (P < 0.03, Kruskal-Wallis (K-W); an increase in the total number of perforators detected per leg (mean Gp I 1.3, Gp II 2.0, Gp III 2.7; P < 0.001, K-W); and in particular an increase in the number of “incompetent”, bidirectional flow, perforarors per leg (mean Gp I 0.03, Gp II 0.9; Gp III 2.1; P c: 0.001, K-W). The number of perforators detected by duplex scanning was greater in the ulcer group (2.8 per limb) than the LDS only group (2.3; P = 0.05, Mann-Whitney U). Similarly, the number demonstrating bidirectional flow was greater in the ulcer group than the LDS only group (2.3 versus 1.7, P = 0.08, Mann-Whitney U). The mean diameter of an “incompetent” perforator (4.9mm) was significantly larger than the mean unidirectional flow. perforator diameter of a “competent”, (2.4 mm; P c 0.01, t-test). Cot&siotzs: Venous reflux and deteriorating clinical status are associated with an increase in the absolure number of detectable calf perforators and the number allowing bidirectional flow imaged per limb. Incompetent perforators are significantly larger than those allowing only unidirectional flow. These data suggest that surgical interruption of calf perforating veins may be important.
20.3 The Use of Cryopreserved Small Aortic Crafrs for Large Vein Substitution J.ERNESTO MOLINA, Minneapolis, Minnesota, USA Acute laceration or chronic large vein obliteration (subclavian, innominate, iliacs, or femorals) carries significant morbidity. No adequate synthetic prostheses exist providing long-term patency to bypass them. Since 1987, we have used descending thoracic aortic allografts preserved by the Cryohfe method obtained from small sized donors for substitution of occluded or irreparable large veins. Twelve patients. (9-56 years old., mean: 36.8) have undergone implant of cryopreserved arterial grafts. Etiology of vein damage: Intraoperative iatrogenic trauma during radical pelvic procedures in four patients. Malignancy in one; poststandard pelvic operations in three; postpregnancy and DVT of the femoral veins in three; and
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Thusday, September 25, 1997
W&on ZO-V&m43 Co-Chairmen:E. Ascher, K.G. Bwnand Mountbatton Room 20.1 Long-term Clinical Follow-up of Venous Thrombol ysis P.E. THORPE, X.X. ZHAN and P.S. DOVGAN, Omana, Nebraska, USA Obje&ve: To assess long-term clinical results of aggressive thrombolysis for lower extremity deep venous thrombosis. Materials aRd M&o&: Ambulatory patients, with deep vein thrombosis (DVT) were evaluated for thrombolysis. Multisegmental thrombosis was treated in 43 patients (48 limbs, six IVC) with catheter and/or flow directed urokinase and heparin between 1988 and 1996. Clinical presentation was acute ( < 14days) in 63% and chronic (> 14 days) in 37%. While 30% had isolated acute venous occlusion, 70% had acute occlusion and chronic changes by phlebography. Oral anticoagulation was established before discharge and continued for at least 6 months. Baseline duplex and/or phlebography were compared to completion studies by an independent evaluator. Long-term follow-up was documented by duplex and physical examinations, a blinded telephone interview and results compared to anticoagulant treated patients. Rest&s: Delivery of urokinase was achieved in all patients; Six major procedure-related complications occurred including one death c 30 days. Early clinical success was 46/48 (96%). Five limbs were lost to follow-up, due to death (four) and arterial insufficiency (one). In total, 32145 (71%) limbs were followed > I2 months with a mean follow-up of 3.5 months range (6-92). No recurrent DVT occurred in 40/45 (90%). Longterm assisted clinical success was 43/45 (96%). Concfusiorcs: Patients presenting with acute DVT often have chronic venous pathology. Long-term results after thrombolytic therapy show a decreased incidence of recurrent thrombosis and chronic venous insufficiency compared to anticoagulant treated patients. Post thrombotic pain and edema is less severe especially in patients treated for an initial acute thrombosis. Thrombolysis appears to lessen the degree of disability associated with chronic/recurrent DVT.
20.2 Calf Perforating Veins; the Relationship Between Number, Size and Flow Patterns and the Haemudynarnit and Clinical Severity of Chronic Venous Ens&iciency UI! STUART, A.W BRADBUEE: D. ADAM, P. ALLAN and C.V. RUCKLEY, Edinburgh, UK Aim: To determine the relationship between severity of venous disease and the diameter, number and flow-patterns perforating veins.
CARDIOVASCULAR SURGERY SEPTEMBER 1997
of calf
Patients: Group (Gp) I, 31 limbs with no clinical or duplex evidence of venous disease; Gp II, 69 limbs with uncomplicated varicose veins only and Gp III, 61 limbs with complicated chronic venous insufficiency (22 lipodermatosclerosis (LDS) only and 39 with an open or healed ulcer). Methock Colour-flow duplex scanning to determine sites of reflux and photoplethysmography to determine the half venous refilling times (VRT SO). Results: Increasing clinical severity of venous disease was associated with a decrease in VRT 50 values (P < 0.03, Kruskal-Wallis (K-W); an increase in the total number of perforators detected per leg (mean Gp I 1.3, Gp II 2.0, Gp III 2.7; P < 0.001, K-W); and in particular an increase in the number of “incompetent”, bidirectional flow, perforarors per leg (mean Gp I 0.03, Gp II 0.9; Gp III 2.1; P c: 0.001, K-W). The number of perforators detected by duplex scanning was greater in the ulcer group (2.8 per limb) than the LDS only group (2.3; P = 0.05, Mann-Whitney U). Similarly, the number demonstrating bidirectional flow was greater in the ulcer group than the LDS only group (2.3 versus 1.7, P = 0.08, Mann-Whitney U). The mean diameter of an “incompetent” perforator (4.9mm) was significantly larger than the mean unidirectional flow. perforator diameter of a “competent”, (2.4 mm; P c 0.01, t-test). Cot&siotzs: Venous reflux and deteriorating clinical status are associated with an increase in the absolure number of detectable calf perforators and the number allowing bidirectional flow imaged per limb. Incompetent perforators are significantly larger than those allowing only unidirectional flow. These data suggest that surgical interruption of calf perforating veins may be important.
20.3 The Use of Cryopreserved Small Aortic Crafrs for Large Vein Substitution J.ERNESTO MOLINA, Minneapolis, Minnesota, USA Acute laceration or chronic large vein obliteration (subclavian, innominate, iliacs, or femorals) carries significant morbidity. No adequate synthetic prostheses exist providing long-term patency to bypass them. Since 1987, we have used descending thoracic aortic allografts preserved by the Cryohfe method obtained from small sized donors for substitution of occluded or irreparable large veins. Twelve patients. (9-56 years old., mean: 36.8) have undergone implant of cryopreserved arterial grafts. Etiology of vein damage: Intraoperative iatrogenic trauma during radical pelvic procedures in four patients. Malignancy in one; poststandard pelvic operations in three; postpregnancy and DVT of the femoral veins in three; and
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