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Purpose The intraoperative classification of recurrent veins at the saphenofemoral junction as neovascularization is based on certain macroscopic criteria. The validity of this neovascularization identification by the surgeon was evaluated by histologic and immunohistochemical examinations of the resected veins as the gold standard. Methods One hundred-four patients (mean age 57 ± 10.9 years) with 130 affected extremities underwent redo surgery of the saphenofemoral junction for recurrent varicose veins at a mean of 12.0 ± 7.9 years after the initial stripping of the greater saphenous vein. The surgeon used intraoperative findings to classify the recurrent veins as neovascularization (group A), no neovascularization (group B), or unclear findings (group C). The resected veins then underwent histologic and immunohistochemical examinations and were again classified into the same three groups (a, neovascularization; b, no neovascularization; c, unclear) according to the histologic results. Results The operating surgeon correctly recognized 16 (41%) of 39 histologically proven neovascularizations, whereas 22 (56%) were not identified. In contrast, 66 (84%) of 79 cases with no neovascularization were correctly identified during the operation. A definite classification by macroscopic criteria was not possible in 4 cases (3%) and the histologic examinations revealed unclear findings in 12 cases (9%). The macroscopic neovascularization identification had a sensitivity of 42.1% and a specificity of 85.7%. The positive predictive value reached 59.3% and the negative predictive value, 75%. Conclusion The validity of intraoperative neovascularization identification is poor, but the surgeon is able to recognize non-neovascularization recurrences with relatively high accuracy. The etiologic classification of recurrent veins at the saphenofemoral junction should not be solely based on macroscopic criteria.

Objective: Because of the dose-dependent increase in bleeding complications, the intraoperative administration of fibrinolytic agents is limited. This limitation impairs the efficacy of fibrinolytic therapy because low-dose fibrinolysis often fails in the treatment of complex deep venous thrombosis (DVT). The aim of this study was to investigate the efficacy and safety of intraoperative high-dose fibrinolytic therapy for extended DVT, which was performed with the regional hyperthermic fibrinolytic perfusion (RHFP) technique. Methods: From January 1993 to June 2001, in 53 patients with extended DVT, unsuccessful venous thrombectomy (recanalization, 50%). Eleven patients (20.8%) showed minimal and 10 patients (18.9%) no recanalization. No lethal complications occurred. One patient (1.9%) had pulmonary embolism develop, and two patients (3.8%) had bleeding complications develop. Conclusion: With the intraoperative use of hyperthermia-assisted high-dose fibrinolysis, improvement of the results of mechanical thrombectomy of extended DVT was possible. The RHFP protected against systemic side effects of the fibrinolysis and show a high safety of application. (J Vasc Surg 2002;36:1219-24.)

Purpose: The aim of this study was to investigate the pharmacokinetics of tissue plasminogen activator (tPA) under the conditions of an isolated extracorporeal circuit. Methods: Plasma levels of tPA were measured in the perfusion solution and in central venous blood before, during, and after the perfusion in seven patients undergoing regional hyperthermic fibrinolytic perfusion with tPA in addition to surgical thrombectomy for extended deep venous thrombosis. Results: After 15 minutes of fibrinolytic perfusion, the level of tPA in the perfusion solution was 10,427 ± 4432 ng/mL, and after 30 minutes the maximum level of 19,726 ± 5630 ng/mL was reached. After 60 minutes when the perfusion was discontinued, tPA concentrations dropped to 15,931 ± 4818 ng/mL. In central venous blood, tPA levels increased to a maximum of 230.7 ± 89.6 ng/mL after 60 minutes of perfusion, which represented 1.4% of the concentration measured in the perfusion solution at the same time. With disconnection of the extracorporeal circuit, the tPA levels in central venous blood decreased rapidly and reached a level of 24.1 ± 8.7 ng/mL after 120 minutes. Conclusion: The use of regional hyperthermic fibrinolytic perfusion in the treatment of extended deep venous thrombosis makes it possible to achieve extremely high concentrations of tPA in the perfusion solution. At the same time, the entry of the fibrinolytic agent into the systemic circulation is minimized. (J Vasc Surg 2001;33:165-9.)

Graft infection continues to be one of the most feared complications in vascular surgery. It can lead to disruption of anastomoses with life-threatening bleeding, thrombosis of the bypass graft, and systemic septic manifestations. One method to ensure adequate limb perfusion after removal of an infected aortofemoral graft is extra-anatomical bypass grafting. We used a minimally invasive, video-assisted approach to implant a crossover iliofemoral obturator bypass graft in a patient with infection of the left limb of an aortofemoral bifurcated graft. This appears to be the first case report describing the use of this technique. (J Vasc Surg 1999;29:730-3.)