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Septic phlebitis of the internal jugular vein, Lemierre's syndrome, is extremely rare. However, Lemierre's syndrome may cause septic pulmonary emboli or result in fatal systemic sepsis, or both, if a timely diagnosis and appropriate treatment are not provided. We present a case of Lemierre's syndrome that occurred in an otherwise healthy young man. In this case, progression to a moribund state was rapid, and surgical intervention proved lifesaving.

Objective: Superficial thrombophlebitis (ST) is a frequent and potentially serious disease if complicated with venous thromboembolism (VTE). Data on risk factors and incidence rates for ST are scarce. It is also unknown whether ST is a risk factor for recurrence of VTE., Methods: After discontinuation of secondary thromboprophylaxis for a first spontaneous VTE, we prospectively observed 615 patients on average for 30 +/- 26 months. Patients with natural coagulation inhibitor deficiency, lupus anticoagulant, or cancer, who were pregnant, or were receiving long-term antithrombotic therapy were excluded. The study outcomes were occurrence of symptomatic ST or objectively documented recurrent symptomatic VTE., Results: ST developed in 45 patients (7.3%) with a first VTE. High factor VIII concentration emerged as an independent risk factor for ST (relative risk [RR], 2.0; 95% confidence interval [CI], 1.0-5.2), compared with lower levels after adjustment for age and sex; factor V Leiden and prothrombin G20210A concentration; hyperhomocysteinemia; high body mass index; and duration of oral anticoagulation therapy. VTE recurred in 12 (27%) of 45 patients with ST and in 67 (12%) of 570 patients without ST. In patients with VTE, subsequent ST emerged as an independent risk factor for recurrent VTE. Patients with ST had twofold higher RR (2.1; 95% CI, 1.0-4.2) for recurrence than did patients without ST after adjustment for putative confounding variables., Conclusion: Patients with a first spontaneous VTE and subsequent ST are at increased risk for recurrent VTE. High factor VIII concentration is an independent risk factor for ST.

Purpose: The use of duplex ultrasound scanning to evaluate the hemodynamic outcome of deep venous thrombosis 7 to 13 years after the original diagnosis., Methods: Duplex ultrasound was used to re-examine 1212 segments of vein from 72 patients (49 men, 23 women) with deep venous thrombosis previously diagnosed by means of phlebography to detect reflux and obstruction and evaluate flow; 611 segments were initially thrombosed and 601 segments were open. To define reflux, reversed flow in 31 healthy persons was measured., Results: In a review of all veins of the 72 patients, 8 patients (11%) had completely normal duplex results in all veins, 33 (46%) had reflux, 6 (8%) had at least one noncompressible vein segment, and 25 (35%) had a combination of both. In the proximal vein segments without initial thrombosis a higher percentage was normal (73%) than in segments with initial thrombosis (46%). There was a significantly higher frequency of reflux (46%, p = 0.05) and noncompressibility (12%, p < 0.01) in initially thrombosed proximal vein segments than in vein segments without initial thrombosis (reflux 25%, noncompressibility 3%). Distal to the knee 125 (17%) of 720 vein segments were not traceable. Significantly more initially thrombosed vein segments were not traceable (p < 0.01). In distal vein segments there was no significant difference in reflux (7% versus 5%) and noncompressibility (10% versus 5%) between vein segments with and without initial thrombosis. Flow was present in 99% of the 611 previously thrombosed proximal and distal segments., Conclusions: Most patients with deep venous thrombosis still had venous abnormalities 7 to 13 years after the initial diagnosis. The most common abnormality was reflux. Significantly more abnormalities were found in initially thrombosed segments. The abnormalities were found in the proximal vein segments and in the distal vein segments, although less frequently in the latter.

Purpose: To determine whether superficial thrombophlebitis (STP) can extend into the deep venous system (DVS) and whether this may result in pulmonary embolization., Methods: All venous duplex ultrasound examinations performed in our vascular laboratory to rule out deep venous thrombosis from June 1, 1994, to June 24, 1996, were reviewed., Results: Of 8313 limbs studied by duplex scanning in 6148 patients, 1756 limbs (21.1%) had a positive result for deep venous thrombosis. STP was demonstrated in 232 limbs (213 patients), of which 20 (8.6%) extended into the DVS. Fourteen (70%) were noted on the initial scan, and six (30%) were detected on serial follow-up scans. Eighteen (90%) originated in the proximal greater saphenous vein and extended across the saphenofemoral junction into the common femoral vein. Nine demonstrated "free-floating" thrombus with a "tongue" extending into the common femoral vein while still attached proximally to the greater saphenous vein. Extension of thrombus from the lesser saphenous vein into the popliteal vein was noted in two cases (10%). One pulmonary embolization was directly observed to occur in real time during scanning. No pulmonary embolization was seen when STP did not involve the DVS., Conclusions: STP can extend into the DVS. In this series STP of the proximal greater saphenous vein extended into the common femoral vein in 8.6% of the cases, of which 10% embolized to the lungs. When the DVS is involved, standard deep venous thrombosis treatment (heparin, warfarin, bed rest) should be instituted. We recommend duplex imaging for STP involving the greater saphenous vein in the thigh to rule out occult deep venous thrombosis. STP is not always benign and self-limiting as previously described.

Purpose: Despite the frequent occurrence of isolated calf vein thrombosis (ICVT), little is known about the long-term clinical and hemodynamic sequelae of this condition. This study was conducted to determine late clinical symptoms and vascular laboratory abnormalities in patients after ICVT., Methods: Of 146 patients in whom ICVT was documented by color flow duplex scanning between 1989 and 1994, 37 were reexamined. Data included history, physical examination, venous recovery time (VRT), and duplex valve closure time (DVCT). A control group with no history of venous disease also underwent identical clinical and hemodynamic testing., Results: Thirty-seven patients (18 male and 19 female) with a median age of 56 years (range, 22 to 76 years) were examined at a mean follow-up of 3.4 years (range, 2.2 to 5.8 years) after the diagnosis of ICVT in 39 extremities. Seventeen subjects (34 extremities) were recruited as normal controls. Presenting symptoms at the time of ICVT included calf pain in 17 patients, calf swelling in seven, pain and swelling in seven, pulmonary symptoms in four, pulmonary symptoms and calf pain in one, and no symptoms in one. In the patients with ICVT, VRT was abnormal in 23% of extremities with ICVT and in 9% of extremities without ICVT. None of the extremities in the control group had an abnormal VRT (p < 0.05). DVCT was abnormal in one or more venous segments in 26% of extremities diagnosed with ICVT and in 6% of control extremities (p < 0.05). Follow-up clinical examination in patients with ICVT revealed 13 (35%) with reticular veins, 10 (27%) with varicose veins, two (5.4%) with edema, one (2.7%) with pigmentation and ulcer (contralateral extremity to ICVT with a previous history of proximal deep venous thrombosis), 13 (35%) with mild discomfort, and one (2.7%) with severe pain. All symptoms attributable to ICVT were mild in nature except in one patient who had severe pain and no physical or hemodynamic vascular laboratory abnormalities at follow-up., Conclusion: At an average of 3.4 years after ICVT, approximately one third of patients showed evidence of mild to moderate venous valvular insufficiency, but mostly in segments not involved with ICVT, and few had significant clinical symptoms attributable to venous disease.

Purpose: To characterize the use and utility of lower extremity noninvasive venous testing (NIVT) in the diagnosis of pulmonary embolism (PE)., Methods: The study is a retrospective case series of consecutive patients in whom PE was suspected who were referred to a large, urban tertiary care center for NIVT. The main outcome measures of the study were the rate of positive results of NIVT, the amount of new information provided by NIVT, and the frequency of management changes that were attributable to NIVT., Results: Forty-one of 450 patients (9%) had deep venous thrombosis (DVT) by NIVT. The prevalence of DVT by NIVT among patients not evaluated by ventilation/perfusion (V/Q) scanning was 8%. The prevalence of DVT by NIVT among patients with a high-probability V/Q scan result before NIVT was 39%, but no management decisions in this group were based on a positive NIVT result and only two decisions were based on negative NIVT results. The prevalence of DVT according to NIVT among patients who had a negative "diagnostic" (low, or very low probability, or normal) result of V/Q scan before NIVT was 2%. The overall frequency of management changes attributed to NIVT was only 2.5%. In the remaining 97% of patients, management was determined by the result of V/Q scanning or of subsequent pulmonary arteriography., Conclusions: In patients in whom PE is suspected, results of NIVT are usually negative for acute DVT. Management decisions are almost always based on V/Q scan or results of pulmonary arteriography and not on NIVT. The utility of NIVT to identify DVT in these patients appears limited, and a more selective approach to its application for the diagnosis of PE should be considered.

Purpose: To identify the presence of occult deep vein thrombosis (DVT) in surgical intensive care unit (SICU) patients and to avoid unnecessary screening, we reviewed our experience with routine duplex screening for DVT in SICU patients., Methods: Over a 24-month period, all patients who were admitted to an SICU with an anticipated length of stay greater than 36 hours were studied to determine the prevalence of risk factors for asymptomatic proximal DVT. Risk factors, demographics, and operative data were collected and analyzed with multilinear regression, t tests and chi 2 analysis., Results: There was a 7.5% prevalence of major DVT in the 294 patients studied. APACHE II scores (14.5 +/- 6.24 vs 10.3 +/- 3.15; p < 0.0001) and emergent procedures (45.5% vs 23.2%; p > 0.0344) were associated with DVT by multifactorial analysis. Age was significant by univariate analysis. An algorithm based on the presence of any one of the three risk factors identified (APACHE II score 12 or more; emergent procedures; or age 65 or greater) could be used to limit screening by 30% while achieving a 95.5% sensitivity for identification of proximal DVT., Conclusion: Absence of all three risk factors indicates a very low risk for DVT (1.1%). Screening of SICU patients is indicated because of a high prevalence of asymptomatic disease. Patients who have proximal DVT require active therapy and not prophylaxis. Costs and resources may be contained by using the above risk factors as a filter for duplex screening.

Purpose: The clinical significance of isolated calf vein thrombosis (CVT), particularly with respect to development of the postthrombotic syndrome, remains controversial. The purpose of this study was to define the early natural history of CVT in relation to persistent lower extremity symptoms, propagation, recanalization, and the development of valvular incompetence., Methods: Over a 116-month period, 499 patients with acute deep venous thrombosis (DVT) were referred to our research laboratory, of whom 58 (12%) had thrombosis confined to the calf veins of at least one extremity. The lower extremities of 268 patients (29 with isolated CVT) were followed-up clinically and with duplex ultrasonography at intervals of 1 day, 7 days, 1 month, every 3 months for the first year, and yearly thereafter., Results: Seventy percent of extremities with CVT were symptomatic at presentation. Although the prevalence of clinical signs and symptoms decreased to 29% by 1 month, 23% of patients had persistent pain, edema, or both at 12 months. In contrast, 9% of uninvolved extremities contralateral to a CVT and 54% of extremities with proximal DVT remained symptomatic at 1 year (p = 0.004). Recanalization proceeded rapidly such that the mean thrombus load was reduced by 50% at 1 month and to zero at 1 year. The prevalence of valvular incompetence progressively increased such that reflux was present in 24% of extremities at 1 year. Although its investigation was not a primary goal of this study, pulmonary embolism was diagnosed at presentation and during follow-up in 11% and 3% of patients, respectively., Conclusions: The natural history of CVT is complicated by persistent symptoms and the development of valvular incompetence in approximately one-quarter of patients. This potential for persistent lower extremity symptoms should be considered in evaluating the clinical relevance of isolated calf vein DVT.

Purpose: The purpose of this study was to determine the incidence and characteristics of Baker's cysts discovered during venous duplex examinations to rule out deep vein thrombosis (DVT)., Methods: We reviewed the vascular laboratory charts of patients found to have Baker's cysts during venous duplex studies to rule out DVT from October 1988 through December 1995., Results: Ninety-five (3.1%) of 3072 patients who underwent venous duplex studies were found to have 111 Baker's cysts. Seven of the 95 had coexistent DVT. Ten patients had ruptured cysts, whereas six patients had cysts that compressed the popliteal vein., Conclusion: The presentation of DVT and that of a Baker's cyst are similar enough to be difficult to distinguish by clinical examination. Careful examination of the popliteal fossa should be performed during venous duplex examinations regardless of the indication for the study.

Purpose: Overall prevalence of pulmonary embolism (PE) in patients with deep venous thrombosis (DVT) isolated to calf veins is low. However, the prevalence of PE in the subgroup of patients with respiratory symptoms and isolated calf vein thrombosis (CVT) is unknown. Such information is important in determining whether patients with CVT only and respiratory symptoms should undergo evaluation for PE. The purpose of this study was to determine the prevalence of PE in patients with respiratory symptoms and isolated CVT., Methods: From 1992 through 1994, all patients assessed by duplex scanning for lower extremity DVT were reviewed, and those found to have isolated CVT and lower extremity or respiratory symptoms were identified. Patients who had respiratory symptoms or later developed respiratory symptoms in addition to lower extremity symptoms underwent pulmonary angiography or ventilation/perfusion (V/Q) scanning. Positive results on pulmonary arteriograms or "high probability" V/Q scans were considered diagnostic of PE., Results: There were 105 patients with isolated CVT and symptoms. Twenty-six patients had respiratory symptoms; nine (35%) had PE and two died. Seventy-nine patients had only lower extremity complaints; five later developed respiratory symptoms. All five had PE and none had progression of CVT on repeat duplex scanning. Neither age, gender, prior DVT/PE, obesity, pregnancy, medication, known malignancy, smoking, recent surgery, or trauma predicted PE., Conclusions: Patients with respiratory symptoms and duplex diagnosed isolated CVT have a high prevalence of PE and require pulmonary angiographic or V/Q scanning to rule out PE.

Purpose: The increasing demand for venous duplex scans despite the relative rarity of detecting acute deep venous thrombosis (DVT) prompted us to review our experience with this diagnostic method., Methods: We retrospectively analyzed the results and indications of 2993 lower extremity venous duplex scans performed between July 1, 1992, and June 30, 1994, at our institution. The indication for the study and the results were prospectively recorded in a computerized data bank. The indications for these studies were leg pain (34%), leg swelling (24%), surveillance for DVT in a patient at high risk (23%), searching for a source of pulmonary embolism (14%), follow-up of previously diagnosed DVT (3%), and other indications (i.e., varicose veins, venous ulcer, 2%)., Results: Overall, 74.1% of all scans were completely normal, and only 13.1% detected acute proximal (popliteal vein or higher) DVT. Scans performed for surveillance (87.3% normal) or source of pulmonary embolism (79.6% normal) were significantly more likely to be normal than when performed for any other indication (p < 0.01). When leg edema or calf tenderness was present, the incidence of acute DVT was significantly greater for all indications (p < 0.0001)., Conclusions: The high percentage of normal venous scans implies that this diagnostic method is being inappropriately used. In the current climate of cost containment our data suggest that indications for venous duplex scans must be better defined and that improved education for referring physicians is needed.

Purpose: The aim of this study was to determine whether, in lower extremities with documented episodes of acute deep venous thrombosis (DVT), incompetence develops in veins that were not the site of thrombosis., Methods: Patients were monitored with serial duplex ultrasonography at 1 day, 1 week, 1, 3, 6, 9, and 12 months, and then annually after detection of acute DVT. The following venous segments were analyzed: common femoral, greater saphenous, proximal superficial femoral, deep femoral, popliteal, and posterior tibial. The incidence of reflux development in both thrombosed and uninvolved segments was determined. Reflux was categorized as either transient or permanent., Results: A total of 227 limbs in 188 patients were serially studied. Mean follow-up was 19.9 months (range 1 to 88 months). Overall, 403 of the 1423 segments (28.3% +/- 2.3%) developed reflux during the study, of which 118 (29.3% +/- 4.4%) had no prior or concurrent history of thrombosis. Considering only the segments that developed incompetence, the percent without prior thrombosis at each level was as follows: common femoral vein (40.0%), greater saphenous vein (53.1%), deep femoral vein (20.6%), proximal superficial femoral vein (23.9%), popliteal vein (8.9%), and posterior tibial vein (31.9%). Valvular insufficiency developing in segments uninvolved with thrombus was more likely to be transient (40.2%) than was the reflux in thrombosed segments (22.6%). This difference was statistically significant (p < 0.05)., Conclusions: Permanent venous valvular damage can occur in the absence of thrombosis after DVT. Reflux in uninvolved venous segments has a different anatomic distribution and is more likely to be transient than the incompetence associated with thrombosis.

Purpose: This study investigated changes in the deep venous system and the development of the postthrombotic syndrome (PTS) after an episode of acute deep vein thrombosis (DVT)., Methods: Seventy-eight patients (41 male patients, 37 female patients) with acute DVT in 83 legs (31 right, 42 left, five bilateral) underwent annual follow-up examinations for 1 to 6 years (median, 3 years) for symptoms and signs of the PTS. A venous duplex scan was performed at each visit to detect obstruction and reflux in the veins, both of which may contribute to the development of the PTS. DVT was primary in 69 limbs and recurrent in 14 limbs., Results: When last examined 49 limbs were free of symptoms, and 34 had the PTS (23 edema only, 11 hyperpigmentation). Only two patients had ulcers during the follow-up period; both patients had the ulcers in areas of hyperpigmentation in limbs with recurrent DVT. The extent of disease was similar in limbs with the PTS (79% multisegment, 18% single segment) and those without the PTS (69% multisegment, 12% single segment). In limbs with the PTS the deep veins were normal in only one (3%), six (18%) showed reflux only, five (15%) obstruction only, and 22 had features of both obstruction and reflux (65%). In limbs without the PTS the deep veins showed no abnormality in nine (18%), reflux only in 17 (35%), obstruction only in six (12%), and reflux with obstruction in 17 (35%). In the 11 limbs with hyperpigmentation nine had obstruction and reflux noted, one had obstruction only, and one had reflux alone., Conclusions: After an episode of acute DVT 12% of the limbs returned to normal by duplex criteria. Although only 13% developed skin complications, 41% had features of the PTS. Limbs with the PTS had more than three times the odds of having combined reflux and obstruction than did limbs without the PTS (odds ratio = 3.5, 0.95 confidence intervals = 1.4, 8.6). Continued study of these patients will determine the course of those limbs with venous abnormalities that have not yet developed symptoms and signs of the PTS.

Purpose: Duplex ultrasonography with distal cuff deflation was used to establish the physiologic reflux duration in different segments of the deep venous system in healthy individuals, and to document the occurrence of deep vein valve incompetence in patients after deep vein thrombosis (DVT)., Methods: Two hundred fifty-two vein segments in 42 legs of 21 healthy individuals and 160 deep vein segments in 27 patients with phlebographically documented DVT were examined with duplex scanning., Results: The duration of reflux in healthy subjects was significantly shorter in distal deep vein segments. Ninety-five percent of the values were less than 0.88, 0.8, 0.8, 0.28, 0.2, and 0.12 seconds, respectively, for the common femoral, superficial femoral, deep femoral, popliteal, and posterior tibial vein (at midcalf and ankle level). The 95 percentile for reflux duration in the superficial venous system was 0.5 seconds for all vein segments, regardless of the location. No significant correlation was found between the reflux peak flow velocity and reflux duration (R = 0.6). The reflux peak flow velocity is therefore not useful as a parameter of the degree of reflux. The patient group was examined with an interval of 18 to 51 months (mean 34 months) after DVT. Forty-five percent of the initially affected segments showed valve incompetence at follow-up (n = 54); only three of 40 segments initially free from thrombus showed pathologic reflux at follow-up (p < 0.01). Reflux durations in most of the incompetent vein segments were two or more times the normal value of reflux duration. The highest prevalence of valve incompetence was found in the superficial femoral and popliteal vein segment (p < 0.01). None of the patients showed valve incompetence at all levels of the deep venous system. A significant (p = 0.04) relation was found between the extent of the initial thrombosis and the number of refluxing vein segments at follow-up, but no correlation was found between the extent of initial thrombosis and the late clinical symptoms (p = 0.16); clinical symptoms could not be related to the number of incompetent vein segments., Conclusions: Duplex scanning allows a good discrimination between physiologic and abnormal reflux duration and is an important tool in the evaluation of the postthrombotic limb. Early assessment after DVT may have prognostic value in individual patients.

Purpose: Although venous valvular insufficiency is well recognized as the most important etiologic mechanism in the development of the postthrombotic syndrome, the factors contributing to valve incompetence after deep venous thrombosis remain obscure., Methods: To establish the relationship between recanalization and valve competence, 113 patients with acute deep venous thrombosis were studied with serial duplex ultrasonography., Results: Median lysis times for segments developing reflux (214 to 474 days) were 2.3 to 7.3 times longer than for corresponding segments not developing reflux (65 to 130 days) for all except the posterior tibial vein. In the posterior tibial vein, median lysis times for those with and without reflux were nearly identical (72 vs 80 days). The median time to onset of reflux was significantly less than the median lysis time in the mid and distal superficial femoral veins and was simultaneous with recanalization in all other segments., Conclusions: Early recanalization is important in preserving valve integrity for all but the posterior tibial segment. However, the small number of patients with reflux despite early lysis (< 1 month) or without reflux despite relatively late lysis (> 9 to 12 months) suggests that other factors may also contribute to the development of valvular incompetence. These factors may be particularly important in the posterior tibial vein, in which lysis time has little relationship to the ultimate development of reflux.

Purpose: This study compares three different modes for measuring hemodynamically significant outflow obstruction in chronic venous insufficiency: (1) arm-foot venous pressure differential combined with foot venous pressure elevation to reactive hyperemia, (2) outflow fraction determination with plethysmography, and (3) calculation of resistance from simultaneously obtained foot venous pressure and calf volume curves., Methods: The three techniques were compared in 15 normal limbs and 19 limbs with documented previous deep venous thrombosis. Outflow fraction and resistance were also measured after reactive hyperemia was induced., Results: The arm-foot venous pressure measurements delineated patients with grades 1 through 4 obstruction (Raju's grading). Resistance calculations correlated well with this grading except in patients with severe grade 4 obstruction, in whom low resistance was found. Outflow fraction determinations had marked overlapping between the different obstruction grades, substantially decreasing sensitivity to detect hemodynamically important outflow obstructions. No correlation with the resistance calculations was shown. Inducing reactive hyperemia did not alleviate these findings. The failure of the outflow fraction and resistance methods to detect significant obstruction is probably attributable to the use of plethysmographic techniques for volume measurement, which appears to give false-negative results as a result of a regional volume shift within the lower limb., Conclusions: The combination of the arm-foot vein pressure differential and the foot vein pressure elevation after reactive hyperemia seems to be the only reliable test currently available for detecting and grading global chronic obstruction.

This study examines the late clinical, hemodynamic, and anatomic results of superficial femoral vein ligation performed in 35 extremities that were followed an average of 13 1/2 years (range, 5 to 22 years). Indications for interruption were to prevent recurrent embolization from distal deep venous thrombosis (14 cases), to prevent emboli in patients with contraindication to anticoagulants (eight cases), to prevent distal reflux in selected patients undergoing iliofemoral thrombectomy (11 cases), and to control reflux in failed venous reconstruction (two cases). Ligation was effective in the prevention of pulmonary emboli as indicated by no significant clinical events and 15 negative postligation ventilation-perfusion scans. Long-term clinical follow-up showed normal (class 0) or near-normal (class 1) extremities in 83%. Fourteen percent developed mild to moderate symptoms of pain or swelling but without ulceration (class 2), and only one case (3%) had ulcerative sequelae (class 3). The only two findings that correlated with worse clinical outcome were the presence of an incompetent profunda femoris or an obstructed greater saphenous vein. Profunda femoris reflux was found in 60% (3/5) of patients with class 2 or 3 sequelae, which was significantly higher than the 14% (3/22) found in those patients with class 0 or 1 results (p < 0.05). Obstruction of the greater saphenous vein was found in 50% of those patients with class 2 or 3 results as opposed to 9% with class 0 or 1 results (p = 0.05). A large collateral vessel between the profunda femoris and the distal superficial femoral or popliteal vein was associated with poor long-term results.(ABSTRACT TRUNCATED AT 250 WORDS)

From December 1986 to December 1990, 268 patients with acute deep vein thrombosis were studied in our laboratory. From this group 107 patients (123 legs with deep vein thrombosis) were placed in our long-term follow-up program. The documentation of valvular reflux and its site was demonstrated by duplex scanning. The duplex studies were done at intervals of 1 and 7 days, 1 month, every 3 months for the first year, and then yearly thereafter. The mean follow-up time for these patients was 341 days. In addition, reflux was evaluated in 502 patients with negative duplex study results and no previous history of deep vein thrombosis or chronic venous insufficiency. In the patients with acute deep vein thrombosis, valvular incompetence was noted in 17 limbs (14%) at the time of the initial study. Reflux was absent in 106 limbs (86%). In this last group reflux developed in 17% of the limbs by day 7. By the end of the first month, 37% demonstrated reflux. By the end of the first year, more than two thirds of the involved limbs had developed valvular incompetence. The distribution of reflux at the end of the first year of follow-up was the following: (1) popliteal vein, 58%; (2) superficial femoral vein, 37%; (3) greater saphenous vein, 25%; and (4) posterior tibial vein, 18%. Reflux seems to be more frequent in the segments previously affected with deep vein thrombosis. Among cases where segments were initially affected with thrombi, after 1 year the incidence of reflux was 53%, 44%, 59%, and 33% for the common femoral vein, superficial femoral, popliteal vein, and posterior tibial vein, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Forty-two consecutive patients diagnosed with superficial phlebitis were seen during a 5-year period. Thirty-five of the 42 patients were outpatients. The diagnosis of superficial phlebitis was made by the presence of palpable subcutaneous cords in the course of the greater saphenous vein or its tributaries in association with tenderness, erythema, and edema. The presence of concurrent deep venous thrombosis (DVT) was assessed by impedance plethysmography in 37 patients, compression venous ultrasonography in 3 patients, and venography in 8 patients. Five of the 42 patients (12%) had DVT. Four of these five patients had a positive impedance plethysmographic or ultrasonographic test result followed by a confirmatory venogram. The fifth patient had a positive ultrasonographic test result, but no venogram was performed. Two of the five patients had clots that involved the popliteal or femoral veins. Four of 23 patients (17%) with superficial phlebitis at or above the knee had DVT. Only 1 of the 19 patients (5%) with superficial phlebitis below the knee had DVT. Three of the five patients with both superficial phlebitis and DVT had undergone surgery recently. All but 3 of the 42 patients (93%) had varicose veins. No patients had clinically apparent pulmonary emboli. DVT occurred in 17% of the patients with above-knee extension of the superficial phlebitis. In the clinical management of superficial lower-limb thrombophlebitis, noninvasive tests should be performed to guide therapy. When superficial phlebitis develops after recent surgery or the superficial phlebitis extends above the knee, diagnostic surveillance should be especially strict. When the noninvasive test results are equivocal, phlebography is indicated to rule out DVT.

Edema of a lower extremity after femoropopliteal bypass surgery is a common problem. To study the causes of this phenomenon we evaluated 72 patients before and after surgery with noninvasive venous testing and venography. We also obtained postoperative lymphangiograms of a sample of 16 patients, eight with and eight without postoperative edema. Patients were sequentially assigned to one of four treatment groups: group A, a lymphatic-preserving inguinal dissection with conventional popliteal dissection; group B, a lymphatic-preserving popliteal dissection with conventional inguinal dissection; group C, lymphatic-preserving inguinal and popliteal dissections; group D, conventional inguinal and popliteal dissections. Twenty-nine (40%) of the 72 patients had postoperative edema. A similar proportion of patients with edema had deep venous thrombosis as patients without edema (3/29 [10%] vs 3/43 [7%], respectively). Patients in group D showed the highest incidence of edema, 17/20 or 85%, a rate significantly higher than the rates in the other three groups (p less than 0.001). Results of lymphangiograms were normal in six of the eight patients without edema (the other two had slight disruption), whereas they showed severe lymphatic disruption in all eight patients with edema. No association was found between edema and type of graft used or severity of preoperative symptoms. This study indicates that deep venous thrombosis is not an important cause of edema that occurs after bypass surgery and that intraoperative lymphatic disruption probably causes most cases of this complication.

The bird's nest filter is a new transvenous stainless steel inferior vena cava filter designed for percutaneous introduction. The filter design eliminates the technical problems associated with other transvenous filters and produces an effective nonthrombogenic barrier to potential pulmonary emboli.

Twenty-nine limbs in 19 patients who had deep venous thrombosis documented by phlebography were studied by hemodynamic techniques 2 to 13 years later (mean, 7 years). Two limbs were found to be "normal." Nine limbs were hemodynamically obstructed; the remaining 18 limbs had developed reflux abnormality. All of the nine limbs with obstruction demonstrated symptoms of severe swelling or ulceration. In contrast, limbs with valve reflux were either asymptomatic or had only mild to moderately severe symptoms. Correspondingly, the reflux hemodynamic derangement was also mild, with reflux confined to a single level (commonly the popliteal valve). The implications of the differences in clinical presentation and hemodynamic profile between this group with post-thrombotic valve reflux and the typical patient with stasis caused by chronic venous insufficiency are explored. The natural history of stasis sequelae of deep venous thrombosis has apparently changed somewhat since the introduction of anticoagulation therapy.

The majority of patients with venous thromboembolism are successfully managed with anticoagulation therapy, but certain patients require inferior vena cava (IVC) interruption. Traditional open operations on the IVC have important disadvantages, among which are significant morbidity and mortality. Twenty years ago work began to develop a transvenous method to interrupt the IVC. As the requirements for a safe and effective method were defined, it became apparent that the best approach would be with a catheter-delivered detachable balloon secured by hyperinflation in the distensible IVC. The concept of a "filter" was discarded because of predicted problems with thrombosis, induced embolism, and device migration. We have treated 135 patients with the Hunter IVC balloon. Sick patients tolerate the procedure, and it is highly effective in preventing pulmonary embolism. Leg morbidity is acceptable, parallels the extent of the phlebitis, and is lessened by leg care and simultaneous anticoagulation therapy. Long-term results with follow-up to 13 years are excellent.

Preferred treatment for thromboembolism when heparin fails or is contraindicated is infrarenal inferior vena cava (IVC) interruption. In the present study suprarenal Greenfield filters were placed in 11 patients in whom routine infrarenal IVC interruption would have been inadequate therapy. As identified by IVC venography, nine patients, including two patients with renal vein thrombi and proteinuria, had partially attached IVC thrombi extending to or above the orifices of the renal veins. One patient had multiple life-threatening pulmonary emboli (PE) on anticoagulation therapy without a known source of emboli and a large patent ovarian vein, and another had an ovarian vein thrombus. Five patients (45%) had a contraindication to heparin therapy, and five (45%) had recurrent PE on anticoagulants. In follow-up (range 3 to 26 months, mean 12.3 months) there has been no documented or suspected recurrent PE, change in renal function, or peripheral edema. There were two deaths secondary to malignancy. IVC patency was demonstrated in all patients studied. Eight patients continue to receive anticoagulants. Based on our clinical experience, our data suggest that suprarenal filter placement is indicated in the following situations: (1) recurrent thromboemboli despite anticoagulation therapy with IVC thrombi extending to or above the renal veins, renal vein thrombosis, previous IVC interruption, or a large patent left ovarian vein or (2) documented perirenal IVC thrombi when anticoagulation therapy is contraindicated. The results of this study indicate that when thromboemboli originate at or above the level of the renal veins in the IVC, suprarenal IVC filter placement is effective therapy.

Anticoagulation is the cornerstone in the treatment of deep vein thrombosis. However, the treatment of septic deep vein thrombosis is controversial. Unlike septic superficial vein thrombosis, venous excision is often associated with limb-threatening or even life-threatening complications. Some authors have suggested thrombectomy as the only means of resolving the sepsis. We reviewed our experience with seven patients who had septic deep vein thrombosis. Phlebography or noninvasive studies documented deep vein thrombosis and blood cultures were positive in all patients. The mean age was 31.5 years with a male/female ratio of 5:2. All patients were treated with anticoagulants and intravenous antibiotics. One patient required surgical exploration for associated abscess of the groin. The patients became afebrile with normal white blood cell counts from 3 to 18 days after therapy was begun. No cases of recurrent sepsis occurred. We conclude that antibiotic therapy and anticoagulation are adequate treatment and therefore consider venous thrombectomy unnecessary.

Ultrasonic duplex scanning was used to study the rates at which lysis of thrombi, valvular incompetence, and symptoms of the postthrombotic syndrome (edema) developed in 21 patients after deep venous thrombosis (DVT). Lysis of thrombi occurred rapidly in most patients. In 11 of 21 patients (53%), recanalization occurred in all segments by 90 days after presentation. In four patients, extension of the initial DVT occurred between 30 and 180 days, despite treatment with warfarin. Valvular incompetence developed in 13 patients during the study period. The number of patent venous segments with incompetent valves increased from the initial presentation to 180 days, at which time 25% of patent segments contained incompetent valves. Valvular incompetence developed in previously thrombosed segments that were initially competent after recanalization and in segments not previously thrombosed. This suggested that although incompetence may occur as a result of a direct effect of the thrombus on the valve, other mechanisms must also be involved. Patients with edema early after DVT (from 7 to 30 days) were more likely to have residual occlusion than valvular incompetence. The late development of edema (from 90 to 270 days) was more closely correlated with valvular incompetence.