Progression of carotid atherosclerosis. Three year follow-up and analysis of risk factors

OBJECTIVE: To elicit the risk factors associated with increasing grades of stenosis in patients with carotid plaque. STUDY DESIGN: Retrospective review of serial duplex scans of the carotid bifurcation. Case note review for documented risk factors. SETTING: Irvine Laboratory of the Academic Department of Surgery, Vascular Section. PATIENTS AND RESULTS: Review of serial duplex scans of the carotid bifurcation was performed on 200 unselected patients who each had a follow-up of at least three years. Definite progression of carotid atherosclerosis was defined as an unequivocal increase in at least one grade by the criteria of Strandness, and was documented in 50 patients (25%). Even if the initial situation is normal or minimal disease ( 50%) in 67% of this patient population. The only risk factor for plaque progression that we defined is hypertension, and this may be spurious. There are no risk factors associated with the subgroup of plaques that progress rapidly above those that progress at a slower rate. CONCLUSIONS: There are no risk factors defined in this population which are associated with advancing carotid atherosclerosis

Risk factors associated with recurrent carotid stenosis

The incidence of restenosis following carotid endarterectomy reported with duplex scanning has ranged from 6-19%. The aim of this study was to determine the importance of risk factors in the development of carotid stenosis following carotid endarterectomy. Two hundred-thirty patients who underwent carotid endarterectomy (nineteen bilateral carotid endarterectomies) and had complete follow-up with duplex scanning for at least one year have been studied between February 1983 and April 1989. Forty six patients developed restenosis (18.5% of carotid endarterectomies) whereas 184 patients did not restenose. All patients were studied for the following risk factors: age, sex, ischemic heart disease, smoking habit, family history of cardiovascular disease diabetes mellitus, hyperlipidemia and peripheral vascular disease. The incidence of ischemic heart disease, a positive family history of cardiovascular disease, hyperlipidemia and diabetes mellitus was significantly increased (p < 0.05) in patients with recurrent carotid stenosis (80.4%, 71.7%, 58.7%, 32.6% respectively) as compared to patients without a recurrent stenosis (55.7%, 33.5%, 31%, 10.5%). None of the above significant risk factors was strongly associated with early (< 2 years) carotid restenosis. There is an increased prevalence of clinical atherosclerotic risk factors such as family history of cardiovascular disease, diabetes mellitus, ischemic heart disease and hyperlipidemia in patients who develop carotid restenosis

Venous hemodynamic abnormalities in patients with leg ulceration

Purpose: Venous ulceration in the leg has been predominantly associated with deep venous insufficiency, although a few reports have implicated the superficial veins. The aim of this study was to identify the distribution of valvular incompetence in patients with active leg ulceration. Patients and methods: Color flow duplex imaging (CFDI) ultrasonography was used to evaluate the entire venous system—superficial, perforator and deep-from groin to ankle in 112 limbs of 94 patients with venous leg ulcers. Results: Seventy two limbs (64%) had multisystem ncompetence and 36 (32%) had one system involved only, whereas in 4 limbs (4%) there was no venous incompetence. Deep venous reflux exclusively was present in 7 limbs (6%) and the perforator system alone was involved only in 3 limbs (3%). However, isolated superficial incompetence was seen in 26 extremities (23%) and combination of superficial with perforator system alone in 23 (21%). In addition, reflux overall in the superficial system (alone and in combination with perforator and deep systems) was seen in 94 limbs (84%). The most common pattern (28%) of abnormality was reflux in all systems, superficial, perforator, and deep. Conclusions: The results of this study show that variable combined patterns account for over two thirds of patients with ulceration. No comprehensive surgical policy for alleviating ulceration can be justified; we suggest that a complete evaluation of all venous systems from groin to ankle with CFDI ultrasonography in patients with venous ulceration is practical on a routine basis and will be particularly valuable before surgery in order to target intervention at specific incompetent sites

The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency

Purpose: The purpose of this study was to identify the distribution of venous reflux in patients with different grades of chronic venous insufficiency (CVI) and corelate the different patterns of reflux with each class.Methods: Color-flow duplex imaging was used to evaluate the entire venous system from groin to ankle in 465 patients (594 limbs) belonging to different clinical CVI classes (0, 1, 2, and 3). A history of previous superficial thrombophlebitis was present in five limbs and past deep vein thrombosis in 70.Results: One hundred seventy eight (30%) limbs were normal and the remaining 416 (70%) had venous incompetence. Deep reflux was present exclusively in 19 limbs (3.2%), and the perforating system alone was involved in only three limbs (0.5%). However, isolated superficial incompetence was seen in 186 limbs (31.3%) and a combination of superficial with perforating system alone was involved in 45 (7.6%). Incompetence in all three systems was seen in 99 extremities (16.7%). In addition, the superficial system was involved in 390 limbs, the perforators in 151, and the deep system in 178 limbs. Only a small percentage of those in class 0 had reflux, and most of them had a single site of incompetence. In class 1 the majority of the limbs had superficial reflux (90.3%), 10.3% of the limbs had deep venous reflux, and 6.9% were competent. Reflux in the superficial system only was seen in 80.7% of the limbs in class 1 and in one fifth of the limbs in classes 2 and 3. Isolated deep or perforator incompetence was rare in all classes. Variable combined patterns of reflux were seen more often in classes 2 and 3 (p < 0.0001). In classes 2 and 3 there were no differences in the number of incompetent sites in the superficial and deep venous systems or the patterns of reflux (p > 0.1). The number of incompetent perforators in class 3 tended to be higher than that in class 2, especially in the below-knee segment, but no significant differences were seen. Distal reflux was present in the majority of the limbs in all symptomatic classes (1, 2, and 3).Conclusions: The distribution and extent of reflux is strongly associated with clinical severity of CVI through class 2. Distal venous reflux is present in at least 80% of the symptomatic limbs. Deep venous thrombosis may not be a prerequisite for the development of skin changes or ulceration in about 75% of the limbs. Superficial venous surgery could be beneficial to at least one third of patients with skin changes or ulceration

Detection of superior mesenteric and coeliac artery stenosis with colour flow Duplex imaging

Measurements of blood velocity in the coeliac axis (CA) and the superior mesenteric artery (SMA) before and after a standard meal in normal people have been studied by several authors. However, information about the ability to detect stenotic lesions is lacking. The aim of our study was to determine the accuracy of Duplex scanning in detecting angiographically proven lesions. Twenty normal volunteers (13 males and seven females) and 24 patients (19 males and five females) with visceral artery stenosis on angiography were examined in the supine position (angle of insonation 60.5) with colour flow Duplex imaging (CFDI) (3.5MHz probe), in the fasting state and after a standard meal at 15, 40, 60 and 90 min. Peak systolic velocity (PSV) and end diastolic velocity (EDV) were determined in both CA and SMA. The PSV was the best indicator of stenosis. After the meal, there was an increase in both PSV and EDV but neither of the postprandial measurements improved the accuracy of the test. The results indicate that CFDI can detect the presence of significant stenosis (>50%) in the CA and SMA with a sensitivity and specificity of >80%

Superficial venous insufficiency: Correlation of anatomic extent of reflux with clinical symptoms and signs

Purpose: The aim of this study was to assess the distribution and extent of valvular incompetence in patients with reflux confined to the superficial venous system and correlate the extent of such reflux with clinical symptoms and signs. Methods: Two hundred fifty-five limbs of 217 patients with superficial venous insufficiency and normal perforating and deep veins were examined with color-flow duplex imaging. One hundred twenty-three limbs (48.2%) of 102 patients had reflux confined to the long saphenous system, 83 limbs (32.6%) of 72 patients had reflux confined to the short saphenous system, and 49 limbs (19.2%) of 43 patients had reflux in both long and short saphenous systems. Results: In the long saphenous system the commonest pattern of reflux was that which extended throughout the length of long saphenous vein (LSV) (47%). Ache, swelling, and skin changes were common in the presence of below knee reflux irrespective whether the thigh segment was involved. Ulceration (8%) was found only in limbs with reflux extending throughout the length of LSV. In the short saphenous system the most common pattern of reflux extended throughout the length of short saphenous vein (SSV) (57%) without involvement of Giacomini or gastrocnemial veins. Ache and swelling were present in 62% and 72% of the limbs, but this incidence was not related to the extent of reflux. Swelling, skin changes, and ulceration occurred only when the whole of the SSV was involved. In the limbs with reflux in both the long and short saphenous systems, the most common pattern of reflux extended throughout the length of both systems (45%). In these limbs the incidence of swelling was 80%. The incidence of skin changes went from 44% when the below-knee segment of the LSV was involved to 73% when reflux occurred throughout the LSV and SSV. Ulceration (14%) was found only in the latter situation. Variable patterns of saphenogastrocnemial termination were seen. In 57.8% of the limbs SSV joined the popliteal vein just above the popliteal crease, whereas the SSV terminated in the thigh in 26.6%. Conclusions: We conclude that ache, ankle edema, and skin changes in limbs with reflux confined to the superficial venous system are predominantly associated with reflux in the below-knee veins. Ulceration is found only when the whole of the LSV is involved (8%) or when reflux is extensive in both LSV and SSV (14%)

The effect of elastic stockings on the elasticity of varicose veins

The aim of this study was to establish the long-term effect of graduated elastic compression on venous elasticity in patients with superficial or deep venous disease and to determine the possible relationship between elasticity and the duration of the disease. The elastic modulus of 29 patients, 19 with superficial vein incompetence and 10 with deep vein incompetence was assessed by the simultaneous measurement of calf volume (determined using strain gauge) and venous pressure (obtained via a dorsal foot vein) during venous occlusion. The measurements were obtained before and after 4 weeks of elastic compression stockings.The elastic modulus K, was defined as stress/strain when the veins were full and was calculated from the pressure/volume relationship. The results show a clear difference in elasticity before and after elastic stockings. Two groups of patients were identified: group 1 with increased elasticity and group 2 with decreased elasticity. There was a negative linear relationship (r=0.88) between increase in elasticity after treatment and duration of venous disease

Venous reflux in patients with previous deep venous thrombosis: Correlation with ulceration and other symptoms

Purpose: Deep vein thrombosis (DVT) in many cases leads to chronic symptoms in the damaged leg, even though the affected veins have recanalized. The major hemodynamic defect in such recanalized veins is reflux. The incidence and extent of reflux has been studied in patients with proven DVT and correlated with concurrent symptoms. Methods: Two hundred seventeen limbs in 183 patients were examined by duplex scanning from January 1989 to October 1992. All limbs had previous DVT diagnosed by venography. Sites and extent (proximal, distal, or both) of reflux were identified by meticulous duplex scanning of the whole venous system and correlated with presenting symptoms. Results: The patients were classified into nine groups on the basis of the classification of the system involved (superficial, deep, or superficial and deep) and whether the reflux was found proximal or distal to the knee or both. Eighty-one limbs belong to chronic venous insufficiency class 1, 92 belong to class 2, and 38 belong to class 3. Reflux was confined to the deep venous system in 84 limbs (38.7%), to the superficial system in 31 (14.3%) limbs, and to both systems in 102 (47%) limbs. It was confined to proximal veins only in 48 (22.1%) limbs, distal only in 56 (25.8%) limbs and throughout the limb in 113 (52.1%) limbs. The incidence of swelling was increased by distal or a combination of proximal and distal reflux regardless of which system was involved. In limbs with superficial venous insufficiency (SVI) or deep venous insufficiency (DVI) only, the incidence of skin changes was not affected by the extent of reflux. However, in limbs with combined SVI and DVI, it was increased in the presence of reflux throughout the limb. Absence of distal reflux was associated with a low incidence of skin changes even in the presence of DVI. Ulceration increased with an increased extent of reflux in the presence of SVI. Absence of superficial reflux was associated with a low incidence, even in the presence of DVI. Conclusions: The data suggest that as far as the skin changes and ulceration are concerned, distal reflux and reflux in the superficial veins are more harmful than reflux confined to the deep veins, even when such reflux extends throughout the deep venous system

Popliteal vein entrapment in the normal population

The aim of this study was to determine the incidence and severity of popliteal vein compression by full knee extension in the normal population. The popliteal veins in 100 healthy volunteers (200 limbs) with no history of previous deep vein thrombosis (DVT) or venous obstruction were examined using duplex scanning with the knee slightly flexed and then fully extended. Knee extension produced complete obstruction in 17 subjects and severe obstruction (40%) in all subjects. With the knee fully extended, severe or complete venous obstruction (outflow fraction <10%) was found in eight subjects. Moderate obstruction (outflow fraction 10-40%) was found in all the remaining 19 subjects. When digital compression of the long saphenous vein was performed, these subjects also demonstrated severe outflow obstruction. Although the incidence of symptoms of functional venous obstruction is rare in the general population, these findings have important implications for venous stasis for patients on the operating table and in those having prolonged bed rest. Studies investigating the association between popliteal vein compression and postoperative deep venous thrombosis are needed