Age-related variations of varicose veins anatomy

Background: Primary varicose veins are commonly considered a progressive disease starting from the saphenous junctions and extending to tributaries in a retrograde fashion along the saphenous trunks. This theory has been criticized by studies indicating different patterns of development and progression of varicose veins. To contribute to the understanding of the pathogenesis of the disease, the anatomy of the venous bed was comparatively evaluated by duplex sonography in patients with varicose veins with a marked difference in age. Methods. The study included 100 varicose limbs in 82 patients aged < 30 years and 238 limbs in 183 patients aged > 60 years. Veins were designated as saphenous veins (SVs), tributaries of the SVs (STVs), and veins not connected with the SVs (NSVs). Four main anatomic patterns were comparatively evaluated: (1) varicose changes only along SVs, (2) varicose changes along SVs and STVs, (3) varicose changes only in STVs, and (4) varicose changes only in NSVs. Results. SVs were normal in 44% of varicose limbs. In most limbs from young subjects, varicose changes afflicted only SVTs (25%) and NSVs (36%). Varicose SVs were more frequent in the older group (62%) than in younger one (39%) owing to a higher prevalence of limbs with combined SV and STV varicosities (respectively, 59% and 37%). In the older group, varicosities in the STVs were more frequently observed in association with incompetence of the SV trunks. Conclusion: The frequent occurrence of normal SVs in varicose limbs of all patients does not support the crucial role commonly credited to SVs in the pathogenesis of primary varicosities. Moreover, the SV trunks were normal in most varicose limbs from young patients. These findings suggest that varicose disease may progressively extend in an antegrade fashion, spreading from the STVs to the SVs. This hypothesis suggests that the saphenous trunks could be spared in the treatment of a relevant number of varicose legs. Prospective longitudinal studies with serial duplex evaluations of large series of extremities are necessary to confirm this hypothesis

Results of antihypertensive treatment by primary and secondary care physicians as assessed by ambulatory blood pressure monitoring

Background We present data from a cross-sectional study on consecutive non-randomized drug-treated mild-to-moderate essential hypertensives, whose blood pressure was ambulatorily monitored for 24 h to evaluate the presence of adequate control. Design Primary and secondary care physicians were invited to send to our clinic drug-treated patients with essential hypertension (JNC VI stages 1 - 2) to undergo 24-h ambulatory blood pressure monitoring (ABPM) while continuing their prescribed medications. Methods The 436 enrolled patients (255 males, 181 females, age 61 +/- 11 years) were left on their therapeutic regime: monotherapy in 208 patients (47.7%) and combination therapy in 228 patients (52.3%). All the patients were divided into two care groups: primary care, 238 patients (54.6%) and secondary care, 198 patients (45.4%). A mean daytime blood pressure less than or equal to 135/85 mmHg was chosen as a definition of adequate blood pressure control. Results Adequate blood pressure control was found in 196/436 total patients (45%); 112/238 patients in primary care (47%) and 84/198 patients in secondary care (42.4%) (P = NS); 94/208 patients (45.2%) in monotherapy and 102/228 patients (44.7%) in combination therapy (P = NS); 125/255 male patients (49%) and 71/181 female patients (39.2%) (P = 0.0428). In the logistic regression model, female sex was associated with a higher risk of inadequate blood pressure control of about 50%. Conclusions Adequate blood pressure control, as assessed by ABPM, is not different in the two settings of family doctor's office and specialist's clinic and is predicted by male gender. The figures of adequate blood pressure control remind us of the rule of halves, regardless of treatment regimes and medications. (C) 2000 Lippincott Williams & Wilkins

Contrast ultrasound imaging: The best method to detect type II endoleak during endovascular aneurysm repair follow-up

Objective: Type II endoleak is the most common complication after endovascular aneurysm repair and require close surveillance. Hence, the need to validate new techniques as alternative to helical CT-scan, the reference standard. The aim of this study is to evaluate the efficacy of Cadence Contrast Pulse Sequencing ultrasound technique with second generation contrast agents in detecting endoleaks, and to compare the results with data obtained from CTA. Methods: 30 patients with endovascular stent grafts, during their regular follow-up consisting in serial CT and ultrasound exams performed at discharge, at one and six months and at one year thereafter, previous informed consent, were enrolled in a prospectic double blind study design in order to compare triphasic helical CT-scan to another adjunctive ultrasound investigation (Cadence CPS technique with Sono Vue). No more than 15 days occurred between the two examinations. In the study were evaluated only data obtained from the comparison of the two concomitant investigations, independently from the follow-up. Variables analysed were changes in the maximum diameter of the aneurysmal sac, presence and type of endoleak, if detected. In the case of disagreement between the two diagnostic tools angiography was performed. Results: One patient dropped out because of violation of the study protocol (a stroke occurred in the time interval between the two investigations). Both exams visualised patency and proper graft placement in all the remaining patients. Aneurysmal diameters with both investigations overlapped (r :0.98). In 21 patients no endoleak s was detected with a significant aneurysmal sac shrinkage (P<0.001). In seven patients both methods confirmed presence of endoleak. Ultrasonography detected all type of endoleaks, while CT-scan was uncertain in one. Moreover, in one patient CT-angiography showed an increased aneurysmal diameter without other evidence, while a contrast ultrasound investigation disclosed a type II low-flow endoleak, confirmed by angiography. Conclusions: the Cadence Contrast Pulse Sequencing with echo contrast agent is an ultrasound technique that substantially improves the ultrasound diagnostic reliability

Skin iron deposition characterises lipodermatosclerosis and leg ulcer

Background: It is commonly reported that chronic venous disease (CVD) increases the skin iron content in which the excess is stored as haemosiderin. Despite increasing interest in the rote of haemosiderin in venous ulceration, no study has systematically evaluated the occurrence of iron overload in the limbs of patients with CVD. Purpose: To evaluate skin haemosiderin deposition in relation to the presence and severity of skin changes in CVD legs designated according to the clinical, etiologic, anatomic and pathophysiologic (CEAP) classification. Methods: A total of 85 skin biopsies were taken from the medial aspect of 49 limbs with CVD of CEAP clinical stages C2, C3, C4 and C6. The content of ferric ions was assessed by Pert's Prussian Blue (PPB) stain. Results: No haemosiderin deposition was found in normal skin of C2, C3 and C4A legs, in less severe regions of pigmentation and in some parts of more severely affected limbs. Haemosiderin was always present in lipodermatosclerotic skin and ulcers. Occasionally, haemosiderin was found in the apparently normal perilesional skin of C4b and C6 legs. The regenerating dermis at the base of healing ulcers showed none or light haemosiderin deposition. Conclusion: Iron overload is not present in the less severe stages of skin damage due to CVD but lipodermatosclerosis and leg ulcers are always accompanied by haemosiderin deposition. In fact, no severe skin changes occur in CVD legs until iron overload occurs. Our results are in agreement with previous reports suggesting that a genetic inability to counteract skin iron overload is present in these patients. A more detailed analysis of disordered iron metabolism should be undertaken in CVD patients. (C) 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved