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Implication of noninvasive venous testing in the selection of patients for venous reconstructive surgery Mark D
JOURNAL OF VASCULAR Volume 18, Number 3
SURGERY
Meeting
($65,000 to $82,OOO/QALY) and hypertension treatment ($11,000 to $47,OOO/QALY). We conclude that early surgery for AAAs less than 5 cm diameter can provide a cost-effective survival benefit for properly selected patients. Randomized prospective study of angioscopically assisted in situ saphenous vein grafting Daniel G. Clair, MD, John A. Mannick, MD, Anthony D. Whittemore, MD, and Magruder C. Donaldson, MD, Brigham & Women’s Hospital, Boston, Mass. A study was conducted to test the hypothesis that angioscopically assistedvalve lysis and vein branch identification during in situ saphenous vein bypasswould reduce technical causesof graft failure, local operative morbidity rates, and length of hospital stay. Patients requiring primary bypassto an infrageniculate artery were randomly assigned to undergo in situ saphenous bypass with valvulotomy and branch identification either under angioscopic visualization with short intermittent incisions (SCOPE) or under direct vision with a continuous incision (NO SCOPE). Completion angiography was performed in all instances. Data on operative details, morbidity, hospital length of stay and graft patency were collected prospectively and compared. 56 patients entered the study with findings as listed in the table. Use of angioscopy to assistwith preparation of the in situ vein for infrageniculate grafting seems to have no impact on local operative morbidity rate, length of hospital stay, or midterm graft patency. Implication of noninvasive venous testing in the selection of patients for venous reconstructive surgery Mark D. Iafrati, MD, Harold A. Welch, MD, Thomas F. O’Donnell, Jr., MD, and Michael Belkin, MD, Nav England Medical
Center, Boston, Mass.
Deep venous reconstructive surgery for chronic venous insufficiency is usually reserved for patients with Society for Vascular Surgery/International Society for Cardiovascular Surgery stage 3 disease. Although lipodermatosclerosis is present in both stage 2 and 3, it is the loss of epithelial integrity (ulcer) that has dictated surgical consideration. Two new noninvasive tests of venous function, air plethysmography (APG) and duplex measurement of valve closure time (XT), are available. APG measures venous filling index (VFI), a measure of
abstracts
Study results (Clair et al.) No scope
Scope Diabetes Claudication Critical ischemia Open lesion Poplitealgr& Infrapopliteal graft Mean operativetime (min.) Wound complications Earlygraft occlusion Mean postoperativelength of stay (days) Rangepostoperativelength of stay (days) Primarypatency,36 mo Secondarypatency,36 mo
(n = 29)
(n = 27)
9 (31%)
12 (44%)
5 (19%)
10 (35%) 19 (65%) 9 (31%)
22 (81%) 17 (63%)
13 (45%) 16 (55%)
10 (37%) 17 (63%)
242 3 (10%) 2 (7%)
1 (4%)X
206 2 (7%) 8.6
8.1
2-25
2-21
63% 77%
61% 88%
*p < 0.05
reflux; ejection fraction (EF), an assessmentof calf muscle pump function; and residual volume fraction (RVF), which correlates with ambulatory venous pressures. VCT assessment with the Van Bemmelan method provides site-specific measurement of the degree of reflux. To determine whether there are any hemodynamic differences between the three clinical stages, 56 limbs in 38 patients were studied with APG and VCT, with results depicted in the table as mean + SE. Analysis of variance of these data identified sign&cant differences between cliical stages only for VFI measurements. However, when limbs with clinical grade 0 and 1 were grouped as mild diseaseand 2 and 3 as moderate to severe, the following significance data was derived from t tests: VFI, p = 0.004; EF, p = 0.9; RVF, p = 0.06; Popliteal (VCT),p = 0.02. Tests of valvular reflux (VFI and VCT) more closely correlated with clinical grade than either EF or RVF. Although there were differences in venous hemodynamics, as measured by APG and VCT, between limbs with mild versusmoderate to severechronic venous insufliciency, no difference could be observed between stages 2 and 3. Therefore the progression from lipodermatosclerosis alone to ulcer is probably related to microcirculatory changes or other mechanisms not assessedby conventional noninvasive venous testing. Consideration should be given to surgically correcting severe reflux (VFI > 7 ml/set or popliteal VCT > 3.5 set) in selected patients with stage 2 diseasebefore it progresses to ulcers.
Results (Iafrati et al.) VFI Chcal 0 Normal 1 2 3
stafle
No. l&nbs 10 8 15 23
(mllsec) 2.2 6.1 7.8 8.2
2 + zk k
0.3 2.1 1.5 1.1
539
52.9 56.2 55.1 49.2
” r 5 k
7.8 11.5 7.8 6.3
24.7 35.9 42.8 39.2
RVF
Popbteal VCT
cw
(set)
k f -c +-
4.9 8.9 5.9 7.2
0.1 2.8 3.6 3.7
2 + -c k
0.04 1.7 1.2 0.7
SURGERY
Meeting
($65,000 to $82,OOO/QALY) and hypertension treatment ($11,000 to $47,OOO/QALY). We conclude that early surgery for AAAs less than 5 cm diameter can provide a cost-effective survival benefit for properly selected patients. Randomized prospective study of angioscopically assisted in situ saphenous vein grafting Daniel G. Clair, MD, John A. Mannick, MD, Anthony D. Whittemore, MD, and Magruder C. Donaldson, MD, Brigham & Women’s Hospital, Boston, Mass. A study was conducted to test the hypothesis that angioscopically assistedvalve lysis and vein branch identification during in situ saphenous vein bypasswould reduce technical causesof graft failure, local operative morbidity rates, and length of hospital stay. Patients requiring primary bypassto an infrageniculate artery were randomly assigned to undergo in situ saphenous bypass with valvulotomy and branch identification either under angioscopic visualization with short intermittent incisions (SCOPE) or under direct vision with a continuous incision (NO SCOPE). Completion angiography was performed in all instances. Data on operative details, morbidity, hospital length of stay and graft patency were collected prospectively and compared. 56 patients entered the study with findings as listed in the table. Use of angioscopy to assistwith preparation of the in situ vein for infrageniculate grafting seems to have no impact on local operative morbidity rate, length of hospital stay, or midterm graft patency. Implication of noninvasive venous testing in the selection of patients for venous reconstructive surgery Mark D. Iafrati, MD, Harold A. Welch, MD, Thomas F. O’Donnell, Jr., MD, and Michael Belkin, MD, Nav England Medical
Center, Boston, Mass.
Deep venous reconstructive surgery for chronic venous insufficiency is usually reserved for patients with Society for Vascular Surgery/International Society for Cardiovascular Surgery stage 3 disease. Although lipodermatosclerosis is present in both stage 2 and 3, it is the loss of epithelial integrity (ulcer) that has dictated surgical consideration. Two new noninvasive tests of venous function, air plethysmography (APG) and duplex measurement of valve closure time (XT), are available. APG measures venous filling index (VFI), a measure of
abstracts
Study results (Clair et al.) No scope
Scope Diabetes Claudication Critical ischemia Open lesion Poplitealgr& Infrapopliteal graft Mean operativetime (min.) Wound complications Earlygraft occlusion Mean postoperativelength of stay (days) Rangepostoperativelength of stay (days) Primarypatency,36 mo Secondarypatency,36 mo
(n = 29)
(n = 27)
9 (31%)
12 (44%)
5 (19%)
10 (35%) 19 (65%) 9 (31%)
22 (81%) 17 (63%)
13 (45%) 16 (55%)
10 (37%) 17 (63%)
242 3 (10%) 2 (7%)
1 (4%)X
206 2 (7%) 8.6
8.1
2-25
2-21
63% 77%
61% 88%
*p < 0.05
reflux; ejection fraction (EF), an assessmentof calf muscle pump function; and residual volume fraction (RVF), which correlates with ambulatory venous pressures. VCT assessment with the Van Bemmelan method provides site-specific measurement of the degree of reflux. To determine whether there are any hemodynamic differences between the three clinical stages, 56 limbs in 38 patients were studied with APG and VCT, with results depicted in the table as mean + SE. Analysis of variance of these data identified sign&cant differences between cliical stages only for VFI measurements. However, when limbs with clinical grade 0 and 1 were grouped as mild diseaseand 2 and 3 as moderate to severe, the following significance data was derived from t tests: VFI, p = 0.004; EF, p = 0.9; RVF, p = 0.06; Popliteal (VCT),p = 0.02. Tests of valvular reflux (VFI and VCT) more closely correlated with clinical grade than either EF or RVF. Although there were differences in venous hemodynamics, as measured by APG and VCT, between limbs with mild versusmoderate to severechronic venous insufliciency, no difference could be observed between stages 2 and 3. Therefore the progression from lipodermatosclerosis alone to ulcer is probably related to microcirculatory changes or other mechanisms not assessedby conventional noninvasive venous testing. Consideration should be given to surgically correcting severe reflux (VFI > 7 ml/set or popliteal VCT > 3.5 set) in selected patients with stage 2 diseasebefore it progresses to ulcers.
Results (Iafrati et al.) VFI Chcal 0 Normal 1 2 3
stafle
No. l&nbs 10 8 15 23
(mllsec) 2.2 6.1 7.8 8.2
2 + zk k
0.3 2.1 1.5 1.1
539
52.9 56.2 55.1 49.2
” r 5 k
7.8 11.5 7.8 6.3
24.7 35.9 42.8 39.2
RVF
Popbteal VCT
cw
(set)
k f -c +-
4.9 8.9 5.9 7.2
0.1 2.8 3.6 3.7
2 + -c k
0.04 1.7 1.2 0.7