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Comparison of venous reflux assessed by duplex scanning and descending phlebography in chronic venous disease
JOURNAL OF VASCULAR Volume 20, Number 4
SURGERY
C, Bertin F, Ghossein Y, Gandara F, Rolle F, Lacroix P. J Mal Vast 1993;18:13-7. Backpund: The purpose of this article is to examine the natural history and to review the management of isolated iliac aneurysms at the University Hospital of Limoges (France). The results suggest that there should be increased awareness and aggressive management of this vascular disorder. Methods and Results: Forty-eight patients with 77 isolated iliac aneurysms were evaluated retrospectively during a 21 -year period (1970 to 1990). The aneurysmswere atherosclerotic in 38 patients (79%) and mycotic in two patients (4%), and the causecould not be determined in eight patients ( 17%). Male predominance (7 : I), with agesranging 48 to 86 years (mean 67 years), characterized this group. Isolated iliac aneurysm was found to involve the common iliac artery in 70% of the patients, the internal iliac artery in 18% of the patients, and the external iliac artery in 12% of the patients. Aneurysm size ranged 2 to 10 cm. Most patients had symptoms (44/48) and among those, 15 patients were first seen for a rupture. Five patients did not undergo operation, four because of the limited size of the aneurysm, and one because of extensive arterial calcifications. Aneurysm ligation or endoaneurysmorrhaphy associatedwith graft interposition was done in 41 patients. The postoperative mortality rate was 10.4% (five patients) . The causesof postoperative death included graft infection (two patients), cardiac insufficiency (one patient), and kidney failure (one patient) and was unknown in one patient. Nonlethal postoperative complications occurred in five patients, and included lower extremity ischemia (three patients), graft infection (one patient), and graft occlusion (one patient). Fourteen patients (29%) were lost to followup. Twenty-seven patients (56%) had a mean follow-up of 38 months. Among those, patencywasachievedin 21(77%). Summay: In this series isolated iliac aneurysms were not infrequent and represent 12% of all aortoiliac aneurysms observed during a 21-year period in this hospital. Early diagnosis was rarely done, most of these aneurysms were discovered when they became symptomatic (91%) or were ruptured (31%). This late diagnosis explained the 21% postoperative morbidity and mortality rate observed in this series. Isolated iliac aneurysms demonstrate expansile growth with a high risk of rupture. When diagnosed electively, they should be treated aggressively by elective endoaneurysmorraphy coupled with graft interposition. Comwnts: Early diagnosis of isolated iliac aneurysm is difficult but essential to obtain. The physical signs associated with iliac artery aneurysms are more difficult to discern than those of abdominal aortic aneurysms. Systematic screening of aortic and iliac aneurysms by echography of aged male population is the modality of choice to detect asymptomatic isolated iliac aneurysms and to obtain better surgical results. Jean-Baptiste I&o, MB lJni9enity of Pcntims
Poitiem,
France
Abstracts
671
Comparison of venous r&ux assessedby duplex scanning and descending phlebogaphy in chronic venous disease Baker SR, Burnand KG, Summerville KM, Thomas ML, Wilson NM, Browse NL. Lancet 1993;341:400-3. Bmkpmnd: The purpose of this study was to compare descending phlebography and duplex scanning in the assessmentof venous reflex. Metboa? atsd Results: Ninety-eight limbs in 52 patients with clinically diagnosed and healed venous ulcers were included in the study. Ail studies were done within 3 weeks of complete healing of all ulcers.A venous abnormality was considered to be present in the limbs with postthrombotic changes on descending phlebogram or evidence of calf pump dysfunction on the foot volume plethysmogram. All studies were performed with the patient in the supine position. In phlebographic studies, deep vein reflux was graded with Herman’s modification of Kistner’s venous reflux classtication. Kismet’s grade of the descending phlebogram was compared with that of the duplex scan. Both duplex scanning and phlebography were blinded. Duplex scanning was performed with use of a Valsalva maneuver. Veins were examined at specific levelsto enable reflux to be quantitated similar to that of descending phlebOgtWS.
In duplex examinations, venous reflux was defined as a reversalof cephalad flow that lasted longer than 0.5 seconds and had a peak velocity of greater than 10 cm/set. All limbs were also assessed after rapid release of tourniquet compression to detect isolated reflux. The long saphenous vein was also examined by duplex scanning to determine whether reflux was present. Summay: There was mildly good agreement for deep vein reflux during the standard Valsalva maneuver. The same grade was found in 58 limbs between the tests,with a difference of one grade in 27 limbs, and more than one grade in 13 limbs. Descending phlebography underestimated reflex in the lower leg compared with duplex scanning with the half volume refilling time on a foot volume plethysmogram with a below-knee tourniquet. There was no correlation between descending phlebography and half refilling time. Severereflux was seenon descending phlebogram in 10 of the 13 limbs with postthrombotic changes. Comments: In thii study, duplex scanning appears to be a marginally more accurate method for detecting deep venous reflux than descending phlebography and is noninvasive. It enables multiple sites to be studied, including isolated venous segments and short sites, including isolated venous segments and short saphenous reflux, which is not possible with phlebography. Duplex scanning was not able to display any anatomic abnormalities found in postthrombotic limbs that are not associated with reflux. It seems from this study that the evaluation of venous reflux with duplex scanning is a more practical choice for such examination. RichardE. Fy, MD St. Francis Hoqital Indianapolis, Ind.
SURGERY
C, Bertin F, Ghossein Y, Gandara F, Rolle F, Lacroix P. J Mal Vast 1993;18:13-7. Backpund: The purpose of this article is to examine the natural history and to review the management of isolated iliac aneurysms at the University Hospital of Limoges (France). The results suggest that there should be increased awareness and aggressive management of this vascular disorder. Methods and Results: Forty-eight patients with 77 isolated iliac aneurysms were evaluated retrospectively during a 21 -year period (1970 to 1990). The aneurysmswere atherosclerotic in 38 patients (79%) and mycotic in two patients (4%), and the causecould not be determined in eight patients ( 17%). Male predominance (7 : I), with agesranging 48 to 86 years (mean 67 years), characterized this group. Isolated iliac aneurysm was found to involve the common iliac artery in 70% of the patients, the internal iliac artery in 18% of the patients, and the external iliac artery in 12% of the patients. Aneurysm size ranged 2 to 10 cm. Most patients had symptoms (44/48) and among those, 15 patients were first seen for a rupture. Five patients did not undergo operation, four because of the limited size of the aneurysm, and one because of extensive arterial calcifications. Aneurysm ligation or endoaneurysmorrhaphy associatedwith graft interposition was done in 41 patients. The postoperative mortality rate was 10.4% (five patients) . The causesof postoperative death included graft infection (two patients), cardiac insufficiency (one patient), and kidney failure (one patient) and was unknown in one patient. Nonlethal postoperative complications occurred in five patients, and included lower extremity ischemia (three patients), graft infection (one patient), and graft occlusion (one patient). Fourteen patients (29%) were lost to followup. Twenty-seven patients (56%) had a mean follow-up of 38 months. Among those, patencywasachievedin 21(77%). Summay: In this series isolated iliac aneurysms were not infrequent and represent 12% of all aortoiliac aneurysms observed during a 21-year period in this hospital. Early diagnosis was rarely done, most of these aneurysms were discovered when they became symptomatic (91%) or were ruptured (31%). This late diagnosis explained the 21% postoperative morbidity and mortality rate observed in this series. Isolated iliac aneurysms demonstrate expansile growth with a high risk of rupture. When diagnosed electively, they should be treated aggressively by elective endoaneurysmorraphy coupled with graft interposition. Comwnts: Early diagnosis of isolated iliac aneurysm is difficult but essential to obtain. The physical signs associated with iliac artery aneurysms are more difficult to discern than those of abdominal aortic aneurysms. Systematic screening of aortic and iliac aneurysms by echography of aged male population is the modality of choice to detect asymptomatic isolated iliac aneurysms and to obtain better surgical results. Jean-Baptiste I&o, MB lJni9enity of Pcntims
Poitiem,
France
Abstracts
671
Comparison of venous r&ux assessedby duplex scanning and descending phlebogaphy in chronic venous disease Baker SR, Burnand KG, Summerville KM, Thomas ML, Wilson NM, Browse NL. Lancet 1993;341:400-3. Bmkpmnd: The purpose of this study was to compare descending phlebography and duplex scanning in the assessmentof venous reflex. Metboa? atsd Results: Ninety-eight limbs in 52 patients with clinically diagnosed and healed venous ulcers were included in the study. Ail studies were done within 3 weeks of complete healing of all ulcers.A venous abnormality was considered to be present in the limbs with postthrombotic changes on descending phlebogram or evidence of calf pump dysfunction on the foot volume plethysmogram. All studies were performed with the patient in the supine position. In phlebographic studies, deep vein reflux was graded with Herman’s modification of Kistner’s venous reflux classtication. Kismet’s grade of the descending phlebogram was compared with that of the duplex scan. Both duplex scanning and phlebography were blinded. Duplex scanning was performed with use of a Valsalva maneuver. Veins were examined at specific levelsto enable reflux to be quantitated similar to that of descending phlebOgtWS.
In duplex examinations, venous reflux was defined as a reversalof cephalad flow that lasted longer than 0.5 seconds and had a peak velocity of greater than 10 cm/set. All limbs were also assessed after rapid release of tourniquet compression to detect isolated reflux. The long saphenous vein was also examined by duplex scanning to determine whether reflux was present. Summay: There was mildly good agreement for deep vein reflux during the standard Valsalva maneuver. The same grade was found in 58 limbs between the tests,with a difference of one grade in 27 limbs, and more than one grade in 13 limbs. Descending phlebography underestimated reflex in the lower leg compared with duplex scanning with the half volume refilling time on a foot volume plethysmogram with a below-knee tourniquet. There was no correlation between descending phlebography and half refilling time. Severereflux was seenon descending phlebogram in 10 of the 13 limbs with postthrombotic changes. Comments: In thii study, duplex scanning appears to be a marginally more accurate method for detecting deep venous reflux than descending phlebography and is noninvasive. It enables multiple sites to be studied, including isolated venous segments and short sites, including isolated venous segments and short saphenous reflux, which is not possible with phlebography. Duplex scanning was not able to display any anatomic abnormalities found in postthrombotic limbs that are not associated with reflux. It seems from this study that the evaluation of venous reflux with duplex scanning is a more practical choice for such examination. RichardE. Fy, MD St. Francis Hoqital Indianapolis, Ind.