We conclude that 0.375% ropivacaine provides effective anesthesia and superior postoperative analgesia compared with 0.5% lidocaine when forearm IVRA is used.
Varicose veins affect approximately 26% of the adult population and are a frequent cause of discomfort, loss of productivity and deterioration in health-related quality of life.1 Numerous therapies have been de veloped for the treatment of this condition. Conventional open surgical interventions include ligation of the great saphenous vein at the saphenofemor al junction and stripping. Smaller veins have also been treated with phlebectomies. More recently, less invasive modalities, such as foam sclerotherapy, endovenous laser therapy (EVLT) and endovenous radiofrequency ablation (RFA), have also been used. While endovenous approaches are associated with fewer postoperative complications, such as hematoma, pain or saphenous nerve injury, there is currently no strong evidence to suggest an overall advantage for any particular treatment approach. 2The RFA procedure involves using a catheter electrode to deliver a highfrequency alternating radiofrequency current that leads to venous spasm, collagen shrinkage and physical contraction.3 The patient's leg is prepped with antiseptic solution and draped in a sterile fashion. With ultrasound guidance, the vein is cannulated, and local tumescent anesthetic is then injected around the target venous segment. The catheter is then introduced through a sheath. The radiofrequency current is then delivered, resulting in circular homogeneous denaturation of the venous collagen matrix and endothelial destruction at a temperature of 110-120° C. Venous segments 3-7cm in length are treated in 20-second cycles. Patients are instructed to wear 20-30 mm Hg graduated elastic compression stockings for at least 14 days.Compared with conventional open surgery, RFA can be performed in the outpatient setting without the requirement for hospital admission or general anesthesia. However, the procedure is not feasible in tortuous or very small or large veins, and it may be less cost-effective than open surgery because of the cost of the catheters.To our knowledge, our institution was the first in Canada to offer RFA for the management of varicose veins using the venefit procedure with secondgeneration ClosureFast catheters (Covidien). Between 2010 and 2013, 173 pa tients underwent RFA performed by 3 vascular surgeons. The average age of the patients was 52 ± 14 years, and 143 (83%) of the patients were women. Our patients were referred to the clinic either by their family doctors
Lens fiber cells are transparent, highly elongated, epithelial cells. Because of their unusual length these cells represent a novel model system to investigate aspects of epithelial cell polarity. In this study, we examined the fiber cell basal membrane complex (BMC). The BMC anchors fiber cells to the lens capsule and facilitates their migration across the capsule. Confocal microscopy revealed that bundled actin filaments converge beneath the center of each BMC and insert into the lateral membrane at points enriched in N-cadherin. Two other contractile proteins, caldesmon and myosin, were enriched in the BMC, co-localizing with f-actin bundles. The actin/N-cadherin complex formed a hexagonal lattice, cradling the posterior face of the lens. Removal of the capsule caused the tips of the fiber cells to break off, remaining attached to the stripped capsule. This provided a method for assaying cell adhesion and purifying BMC components. Fiber cell adhesion required Mg2+ and/or Ca2+ and was disrupted by incubation with beta1 integrin antibody. BMC proteins were compared with samples from the neighboring lateral membrane. Although some components were common to both samples, others were unique to the BMC. Furthermore, some lateral membrane proteins, most notably lens major intrinsic protein (MIP), were excluded from the BMC. Western blotting of BMC preparations identified several structural proteins originally found in focal adhesions and two kinases, FAK and MLCK, previously undescribed in the lens. These data suggest that the BMC constitutes a distinct membrane domain in the lens. The structural organization of the BMC suggests a role in shaping the posterior lens face and hence the refractive properties of the eye.
Conclusions: Limited ultrasound studies for peripheral arterial disease can establish the presence of disease but are inadequate to guide CDM. Caution should be exercised in the use and interpretation of such protocols.
Objective: The objective of this study was to compare clinical outcomes of cyanoacrylate (CA) and radiofrequency ablation (RFA) in the treatment of varicose veins at our institution. Methods: Between January 2014 and December 2016, there were 335 patients with 476 venous segments who were treated with either CA (n ¼ 148) or RFA (n ¼ 328) for varicose veins at the Vancouver General Hospital vascular clinic. Charts were reviewed to assess demographics of the patients, location and severity of disease, treatment details, and outcome at short-term and midterm follow-ups. Outcome parameters included treatment success and presence of short-term and midterm complications. Results: The average age of patients was 57 6 1 years, with the majority being female (78%) and with an average body mass index of 24.8 6 0.5. Clinical, Etiology, Anatomy, and Pathophysiology classes were 2 (49%), 3 (26%), 4a (22%), and >4b (3%). Of the 148 segments treated with CA, the vein types were as follows: 112 great saphenous veins (GSVs), 24 small saphenous veins, 2 accessory GSVs, and 8 perforator veins. The average amount of CA delivered for GSV treatment was 1.8 6 0.1 mL, with a treatment length of 43 6 1 cm. Subgroup comparison was done for GSV segments. Treatment success was 100% in CA and 99% in RFA. Superficial phlebitis was the most common complication noted at midterm follow-up in 5% of CA and 16% of RFA treatments. There was one patient in each group who had asymptomatic proximal thrombus extension treated with anticoagulation for 2 weeks. Three superficial glue protrusions requiring minor incision and drainage were noted in the CA group. Five patients in the RFA group had persistent numbness and two had nonhealing wounds at the access site. Conclusions: CA is a minimally invasive endovenous technique for treating varicose veins without the need of tumescent analgesia. In our experience, CA offers success rates equivalent to RFA with lower midterm complication rates.
Methods: We retrospectively reviewed vascular surgery patients undergoing thrombolysis between 2005 and 2013. Patients were allocated to the low-fibrinogen group if their fibrinogen level was <1.5 g/L during treatment or to the high-fibrinogen group. Demographics, bleeding complications, and technical and clinical success were statistically analyzed between the groups. Results: A total of 49 patients (22 arterial and 27 venous), with a mean age of 52.0 6 18.4 years, were included. Sixteen patients were allocated to the low-fibrinogen group and 26 to the high-fibrinogen group (fibrinogen levels were not measured in seven patients; none of these patients had any bleeding complications). Patients were significantly younger (41.1 6 17.3 vs 56 6 15.7 years; P ¼ .006) and had a proportionately higher number of venous occlusive events (87.5% vs 42.6%; P ¼ .004) in the low-fibrinogen group compared with the high-fibrinogen group. Other baseline characteristics, including gender, extremities affected, prothrombotic risk factors, contraindications to thrombolysis, baseline fibrinogen, international normalized ratio, partial thromboplastin time, and platelets were similar between the groups. The low-fibrinogen group used a larger total dose of tissue plasminogen activator (tPA; 40.7 6 24.6 mg vs 21.9 6 10.5 mg, P ¼ .009) and had longer duration of tPA infusion (26.8 6 12.9 hours vs 16.9 6 6.6 hours; P ¼ .010). The rates of major and minor bleeding were not significantly different between the low-fibrinogen vs high-fibrinogen groups (2 vs 0 cases of major bleed, respectively, P ¼ .139; 1 vs 4 cases of minor bleed, respectively; P ¼ .633). Secondary outcomes including technical and clinical success rate, in-hospital mortality, hospital length of stay, and secondary procedures were similar between groups. Conclusions: A fibrinogen level of <1.5 g/L during thrombolysis was not associated with an increased risk of bleeding complications; this was despite a larger total dose and longer duration of tPA infusion used.
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