The venous system is, in many respects, more complex than the arterial system and a thorough understanding of venous anatomy, pathophysiology, and available diagnostic tests is required in the management of acute and chronic venous disorders. The venous system develops through several stages, which may be associated with a number of development anomalies. A thorough knowledge of lower extremity venous anatomy, anatomic variants, and the recently updated nomenclature is required of all venous practitioners. Effective venous return from the lower extremities requires the interaction of the heart, a pressure gradient, the peripheral muscle pumps of the leg, and competent venous valves. In the absence of pathology, this system functions to reduce venous pressure from approximately 100 mm Hg to a mean of 22 mm Hg within a few steps. The severe manifestations of chronic venous insufficiency result from ambulatory venous hypertension, or a failure to reduce venous pressure with exercise. Although the precise mechanism remains unclear, venous hypertension is thought to induce the associated skin changes through a number of inflammatory mechanisms. Several diagnostic tests are available for the evaluation of acute and chronic venous disease. Although venous duplex ultrasonography has become the standard for detection of acute deep venous thrombosis, adjuvant modalities such as contrast, computed tomographic, and magnetic resonance venography have an increasing role. Duplex ultrasonography is also the most useful test for detecting and localizing chronic venous obstruction and valvular incompetence. However, it provides relatively little quantitative hemodynamic information and is often combined with measurements of hemodynamic severity determined by a number of plethysmographic methods. Finally, critical assessment of venous treatment modalities requires an understanding of the objective clinical outcome and quality of life instruments available.
GSV occlusion was achieved in >90% of cases after both EVLT and RFA at 1 month. We observed three cases of thrombus protrusion into the CFV after EVLT and recommend early duplex scanning in all patients after endovenous saphenous ablations. DVT prophylaxis may be considered in patients >50 years old. Long-term follow-up and comparison with standard GSV stripping are required to confirm the durability of these endovenous procedures.
Endovenous techniques such as radiofrequency ablation (RFA) and endovenous laser therapy (ELT) have emerged as percutaneous minimally invasive procedures for ablation of incompetent great saphenous veins in patients with varicosity and venous insufficiency. Early reports showed safety and efficacy of both techniques, with excellent technical success rates and few major complications, such as deep vein thrombosis or pulmonary embolism. During our initial experience with ELT in 56 limbs of 41 patients, 39 underwent postoperative duplex scanning. We encountered three cases (7.7%) with thrombus extension into the common femoral vein. All three patients were anticoagulated, and a temporary inferior vena cava filter was placed in one. All remained asymptomatic. The thrombus resolved by 1 month in all three patients. Review of the literature revealed that the incidence of thrombus extension into the common femoral vein or deep vein thrombosis in published clinical series is 0.3% after ELT and 2.1% after RFA. This possibility warrants routine postoperative duplex scanning, more alertness during these procedures, and patient education on this possible complication.
The mortality rate of ruptured AAAs remains excessive, despite improvement over 18 years. Patients older than 80 years with shock or cardiac arrest have the highest mortality rate and should be evaluated for possible endovascular treatment. Because the diagnosis of AAA was unknown in more than 70% of patients, screening of the high-risk population and elective repair are recommended.
CEA can be performed in patients at high risk, with stroke and death rates well within accepted standards. These data question the use of CAS as an alternative to CEA, even in patients at high risk.
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