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Endothermal heat induced thrombosis (EHIT) is a post-procedural entity following endothermal superficial venous ablation that refers to the propagation of thrombus into the adjacent deep vein lumen. It is identified most commonly during the post-procedural surveillance venous duplex ultrasound. EHIT is recognized as a unique post-procedural entity, distinct in clinical behavior from a deep vein thrombosis. The definition, classification systems, pathophysiology, risk factors, treatment, and prevention are all discussed. The understanding of EHIT has advanced considerably, but additional data are required to understand its impact on quality of life and the cost-effectiveness of surveillance.

Evaluation of the outcomes of OSES (oval-shaped external support), a novel device for external valvuloplasty of the great saphenous vein (GSV) for the conservative treatment of superficial venous insufficiency. Between 2012 and 2015, 30 patients underwent external valvuloplasty of the GSV for a total of 32 limbs. Patients were subjected to clinical and instrumental follow-up by a half-year ultrasound for a minimum of 36 months. The main endpoints were the recurrence of varicose disease, persistent or recurrent venous reflux, and venous thrombosis. Varicose recurrence was verified in six limbs on 32 (18.75%). Four limbs (12.5%) presented a recurrence of the reflux even in the absence of varicose veins. Two limbs (6.25%) underwent saphenectomy after the valvuloplasty intervention at 12 and 18 months, respectively, because of the presence of saphenofemoral reflux and varicose recurrences. No case of venous thrombosis of the saphenous trunk was observed. The external valvuloplasty of the GSV is a well-known technique that used to treat the superficial venous insufficiency. The newly introduced OSES device seems to show better midterm results, due to a better alignment of the valve flaps. In our experience, the use of this device gives better long-term results and allowed to extend the indication to patients with saphenic diameters that were considered not eligible for repair. In conclusion, although our data needs further confirmation, OSES device might represents a new interesting opportunity for reconstructive venous surgery.

From an anatomical point of view, recurrences at the saphenofemoral junction (SFJ) could result from various sources. For one, it could be caused by a recanalisation of an originally occluded great saphenous vein (GSV). Secondly, another vein in the junction region could take over the function of the GSV and dilate. A third variation is a – more or less successful – generation of a new vein. In the last case, a sufficient vein could be generated, an insufficient vein could arise, or an inadequate venous regeneration, so that a cluster of frail but incomplete vasculature remains (neovasculature).

The results of studies on treatment of the great saphenous vein (GSV) with sapheno-femoral-junction (SFJ) insufficiency are unclear. Guidelines, however, recommend endovenous laser ablation (EVLA) and ultrasound-guided-foamsclerotherapy (UGFS) for symptomatic varicose large saphenous vein. There are numerous studies on GSV treatment but only a few randomized studies with a follow-up of two years and more. Meta-analyses in most instances included all studies and do not focus on studies with a follow-up of two years and longer. Methods A literature research in Pubmed used the keyword “great saphenous vein treatment”, “large saphenous vein treatment”, “varicose therapy” in conjunction with “randomized controlled trial”, “meta-analysis” and “systematic review”. Of 128 studies only 24 randomized controlled studies investigated the effect of High Ligation and Continuous Stripping (HL + CS), Endovenous Laser Ablation (EVLA), Radiofrequency Ablation (RFA), Liquid Sclerotherapy (LS), and Ultrasound-Guided-Foam-Sclerotherapy (UGFS) and a follow-up of two and more years. Study evaluation included “reflux”, “recurrence”, “therapy technique”, numbers of patients/legs treated, length of follow-up, and primary/secondary study endpoints. Results Most of these studies investigated surgical High Ligation and Continuous Stripping (HL + CS) with a follow-up of two years and more. This technique served a reference technique for other techniques in randomized controlled studies. However, there are major differences in techniques, mode of treatment, definitions, criteria for exclusion and inclusion, and study endpoints.The surgery study group included 1915 legs in 19 studies, the EVLA group 1047 legs in 12 studies and 240 legs in 3 studies with combined HL + EVLA treatment. RFA was used in 299 legs in 4 studies, UGFS in 661 legs in 5 studies, combined UGFS + HL in 39 legs and LS + HL in 92 legs in one study each.EVLA is associated with more reflux and recurrence when compared to HL + CS. RFA shows similar reflux and recurrence rates as surgery. In most studies UGFS and LS is followed by more reflux and recurrence when compared to surgery. Conclusion Due to heterogeneity of studies comparing study results of HL + CS, EVLA, RFA, LS and UGFS is not reliable. UIP or ECOP may form a commission to establish uniform, reliable and accepted study designs for varicose vein treatment to improve comparability of further randomized studies.

Primary avalvular varicose anomaly (PAVA) is a new medical concept defined as primary varicose veins resembling neovascularized tissue on ultrasound examination. PAVAs could be misdiagnosed as recurrence at the saphenofemoral or saphenopopliteal junction, but no studies have yet examined their role before and after venous invasive procedure. In this report, we describe a case of PAVA in a 39-year-old man with symptomatic varicose veins and great saphenous vein truncal incompetence. Six months after radiofrequency ablation of the great saphenous vein, duplex ultrasound revealed complete occlusion of great saphenous vein and partial thrombosis of the still incompetent PAVA.

Objective This prospective randomized controlled study aimed to compare the ultrasound-guided (USG) technique with the standard single-wall puncture technique for epicutaneo-caval catheter (ECC) placement in neonates. Study Design A total of 100 neonates were included in this study. All enrolled neonates were randomly divided into two groups (n = 50): the USG group and the control group. The control group underwent standard single-wall puncture for ECC placement procedures, and the USG group underwent USG ECC placement procedures. Results The first attempt success rates (62 vs. 38%; p = 0.016) and the total success rates (92 vs. 74%; p = 0.017) were higher in the USG group than in the control group. The procedure time was shorter in the USG group than in the control group: 351.43 (112.95) versus 739.78 seconds (369.13), p Conclusion Compared with the standard single-wall puncture method, USG cannulation is superior for neonatal ECC placement, with a higher success rate, and decreases the total procedural time. Key Points

ZusammenfassungDurch die deutsche Leistenrezidivstudie zeigte sich, dass vor allem technische Fehler bei der Erstoperation mit einem zu lang belassenen Stumpf der V. saphena magna Ursache für nachfolgende Krossenrezidive sind. Daher sollten für eine korrekte Krossektomie gewisse Mindestanforderungen gelten. Dazu zählt vor allem eine bündige Ligatur an der Einmündung der tiefen Vene (sogenannte „flush ligation”). Diese ist an der saphenofemoralen Mündung unbedingt zu fordern und an der saphenopoplitealen Mündung, aufgrund der schwierigeren anatomischen Verhältnisse, anzustreben. Weiteres Merkmal einer „korrekten” Krossektomie ist eine adäquate Versorgung des Stumpfes mittels Invertierungsplastik und Elektrokoagulation des Endothels. Zudem sollte vor allem im Bereich der saphenofemoralen Mündung eine kurzstreckige (0,5–1,0 cm lange) Inspektion der V. femoralis communis sowie ein Verschluss der Fossa ovalis erfolgen.

Deep vein thrombosis (DVT) is a serious medical condition that needs prompt diagnosis and treatment. The invasive gold standard contrast venography has largely been replaced by venous ultrasonography which is currently the imaging modality of choice for DVT diagnosis. Radionuclide venography (RNV) is an alternative test for DVT, but a few studies have directly compared RNV with venous ultrasonography. This study aims to determine the agreement between RNV and venous ultrasonography for diagnosis of DVT and to determine the predictive value of different RNV findings for the prediction of DVT as detected by venous ultrasonography. Imaging results from patients who underwent both RNV and venous ultrasonography for suspected DVT no more than 1 week apart were reviewed. Results from both modalities were compared to determine inter-modality agreement. A total of 121 venous segments from 102 lower limbs of 75 patients could be compared. The prevalence of DVT as detected by venous ultrasonography was 39%. RNV and venous ultrasonography had moderate agreement (73.6% agreement, κ =0.48, P < 0.0001). The absence of radiotracer activity from a deep venous segment had a positive predictive value (PPV) of 100% for DVT. Other findings such as isolated great saphenous vein activity had a lower PPV. The negative predictive value of RNV is 97.5% with only one patient out of forty with normal RNV found to have DVT by venous ultrasonography, which suggests that DVT can virtually be excluded in patients with normal RNV.

SummaryBackground: Insufficiency of anterior accessory great saphenous vein (AASV) with a competent great saphenous vein (GSV) is frequently encountered in patients referred for phlebological evaluation. The classic therapeutic approach to treat AASV insufficiency consists of crossectomy and stripping of GSV and all tributaries. In isolated AASV insufficiency, stripping of the AASV combined with foam sclerotherapy of the proximal AASV section is a useful alternative to preserve the GSV. Historically, the combination of phlebectomy and sclerotherapy in a single session was avoided given the perceived and reported risk of complicationsAim: A retrospective analysis of the side effects and complications following phlebectomy of the AASV combined with foam sclerotherapy in one session.Patients and method: Case records of all patients with isolated AASV insufficiency, who underwent a combined procedure (phlebectomy of the AASV and foam sclerotherapy) between 01.01.2013 and 30.11.2016, were evaluated.Results: 28 patients (29 legs) were included. There were no severe side effects or complications in any case. Complete occlusion of the proximal AASV could be demonstrated sono-graphically.Conclusion: The combination of phlebectomy and foam sclerotherapy in one session is an effective and safe treatment option in cases of isolated AASV insufficiency.

SummaryIntroduction: Since it’s description the CHIVA strategy was performed with surgical techniques. After the introduction of endoluminal heat techniques these might be applied also in the CHIVA context.Method: 104 patients were investigated before and 3–6 months after the treatment of the great saphenous vein (GSV) with CHIVA strategy using enoluminal heat techniques to close the groin segment (VNUS Closure-Fast™ or LASER [1470 nm, Intros radial]). General data (age, sex, BMI) and phlebological data (QoL as reflected in VCSS, clinics as C[CEAP], refilling time after muscle pump measured with light reflection rheography, diameters of GSV at the groin and proximal thigh, as well as diameters of the common femoral vein) were measured and compared.Results: Significant reduction of diameters of GSV at proximal thigh from 6.5 ± 1.6 to 3.7 ± 1.1 and VFC from 15.2 ± 2.3 to 14.8 ± 2.2 were recorded, as well as reduction of clinical scores (VCSS from 5.6 ± 3.1 to 2.2 ± 2 and C[CEAP] from 3.2 ± 1 to 2.1 ± 1.1). Refilling time improved from 20.3 ± 11 to 28.8 ± 10.2. Results are comparable to those achieved after surgical crossectomy and published in other series.Conclusion: The disconnection of the insufficiency point at the saphenofemoral junction seems to be possible in the context of CHIVA Strategy applying endoluminal heat technique. No difference could be found between both techniques, Laser or VNUS Closure-Fast™.

SummaryTo evaluate and compare the fiveyear outcome after treatment of a varicose GSV by endovenous thermal laser ablation (EVLA) and radiofrequency ablation (RFA).In this non-randomized, prospective study, patients treated in 2007 and 2008 for complete varicosis of the GSV (CEAP: C2–C6) were divided according to the treatment technique used into three groups: RFA (VNUS ClosureFast™), EVLA 980 nm (ELVeS 980™) and EVLA 1470 nm (ELVeS 1470™). Ultrasound-guided follow-up consultations were conducted 3 days, 3 months, 1 year and 5 years after treatment.589 patients with 643 GSVs (223 RFA, 185 EVLA 980, 235 EVLA 1470) were treated under tumescent local anaesthesia. No major complications occurred and minor complications were rare (4.7–12.2 %, p=0.135).66 % (RFA), 15 % (EVLA 980) and 32 % (EVLA 1470) of the patients were pain-free without post-operative analgesics. After 5 years, 86 % (RFA), 90 % (EVLA 980) and 93 % (EVLA 1470) of the veins were occluded (p=0.096). Ultrasound imaging revealed reflux in treated GSVs in 5–8 % of cases (p=0.73). A second ablation of the previously treated GSV was required in 5 % (RFA), 2 % (EVLA 980) and 2 % (EVLA 1470) of the patients (p=0.28).Endoluminal thermal ablation is an easy, safe and well tolerated method for the treatment of varicosis. Radiofrequency ablation is less painful than EVLA. RFA and EVLA 1470 are equally effective for vein closure.

SummaryBackground A long stump and neovascularisation are commonly discussed reasons for recurrence of varicosis in the groin after “disconnection” of the saphenofemoral junction (SFJ) and stripping of the great saphenous vein (GSV). A third possible reason for recurrence with non femoral reflux emerging from tributaries of the junction region, is often underrated. The aim of the study was to report on the source of reflux for recurrent varicose veins of the thigh in patients who already had a history of disconnection of the SFJ and stripping of the GSV.Methods In this two-centre study, consecutive patients with a history of disconnection of the SFJ, stripping of the GSV and visible or palpable varicose veins of the thigh region were included. Their data and venous diagnostics (DPPG, duplex scan) were recorded and evaluated by a standardised protocol.Results 101 legs were included. In 58.4 % there was a long stump of the GSV as a source for variose veins of the thigh. In the other legs (42,6 %) the source for the reflux was not a long stump with contact to the femoral vein but residual tributaries of the SFJ, e.g. the superficial epigastric vein or the superficial circumflex iliac vein.Conclusions Residual refluxive tributaries of the SFJ seem to be an important source for recurrent varicose veins of the thigh. Further prospective studies should focus on suitable therapeutic options.

Summary Background Great saphenous vein (GSV) incompetence is involved in the majority of cases of varicose disease. Stratification of venous disease severity is still difficult. This study aims to correlate GSV diameters with C of CEAP and the venous clinical severity score (VCSS). Methods Legs without GSV reflux (Control legs, Group 1) and legs with untreated isolated GSV reflux and varicose veins limited to the GSV territory (Group 2) were studied clinically and with duplex ultrasound in a prospective study. The GSV diameters were measured both next to the saphenofemoral junction (SFJ) and at proximal thigh (PT) and correlated to the C of CEAP and VCSS. Results The control legs-group 1 were: n=33, 6 male, mean age 53, mean BMI 26.The legs with reflux-group 2 were: n=78, 16 male, mean age 54, mean BMI 27.The mean diameters for the SFJ ( ± SD) for groups 1 and 2 were 6.4 ± 1.8 and 9.9 ± 3.4. For PT they were 3.6 ± 0.9 and 5.9 ± 1.8 respectively. In legs with reflux the SFJ diameter correlates strongly with the PT diameter (r=0.69) and moderately with the C of CEAP and VCSS; 0.42 and 0.45 respectively. The PT diameter correlates slightly better with the C of CEAP and VCSS than the SFJ diameter (0.55 and 0.57). The mean values of VCSS for groups 1 and 2 were 0.70. and 4.69. The C of CEAP and VCSS show a strong correlation among them with r=0.79 in group 2 and 0.80 in the whole sample. Conclusion The GSV diameters next to the SFJ and particularly at the PT in patients having reflux correlate strongly with both the C of CEAP and VCSS. Recording the GSV diameters at the SFJ and PT in a standardized way may improve comparison of published data and contribute to choice of treatment in the future.

SummaryIntroduction: The endovenous thermal ablation of the great saphenous vein due to varicosis changes the blood circulation in the groin. This could affect the venous drainage of the penis, especially the drainage of the corpus spongiosum over the external pudendal vein. There are a few cases in our clinic until now which had an enhanced swelling of the glans penis beside an erection.Objective: Is the enhancement of penile swelling caused by the targeted thermal ablation of the GSV without affecting the saphenofemoral tributaries in the groin?Material and Methods: To verify this enhanced swelling of the glans penis and change in the erectile function we want to ask 56 patients with a modified IIEF questionnaire.The IIEF is a validated questionnaire with a additional question for the swelling of the glans. We check the reliability of the additional question with 16 healthy males.Possible results: Hypothesis 1 (H+): There is an improvement of the erectile function. Hypothesis 2 (H-): There is a decrease of the erectile function. Hypothesis 3 (H0): There is no change of the erectile function. Schedule: 1.Preliminary assessment: Sept. 2014: ethical approval, Reliability of the additional question. 2. Main assessment: Oct. 2014 to May 2016. 3. Analysis of the data: May 2016 to Aug. 2016 4. Report of data: August 2016.

Background Occupational edema is reported to occur in healthy individuals after working in a sitting or standing position for extensive periods of time. It can be associated with feelings of tiredness, heaviness of the legs, and pain. Three licensed medical devices were compared in their management of occupational edema. Subjects and Methods A total of 10 subjects were recruited from a clinical workspace. Right leg volume and great saphenous vein diameter was measured in the morning, and 6 hours later. On subsequent separate days, grade 2 graduated compression stockings (Active Compression Socks, Mediven, United Kingdom), geko (Firstkind Ltd, United Kingdom), and Revitive (Actegy Ltd, United Kingdom) were used bilaterally according to manufacturer's instructions. Results Leg volumes increased by median 41 mL (p 0.05) with no intervention. Percentage increase in leg volume was found to be significantly reduced by stockings compared with control (-1.7%, p 0.01), and were more effective than electrical devices. Changes in vein diameter poorly correlate with leg volume changes. Conclusion Occupational edema can occur over as little as 6 hours. All devices were well tolerated and reduced leg swelling. Stockings were the only device to significantly reduce leg swelling in this small trial.

SummaryIntroduction: Endovenous heat-induced thrombosis (EHIT) is a known complication after endovenous ablation of the superficial varicose veins (incidence rate 0–6 % (varies by definition and diagnostic algorithm). However, only expert suggestions for indication, duration and dosing of treatment drugs exist. The most common recommendation is low-molecular weight heparin in half-therapeutic dosage for EHIT class 2 and therapeutic dosage for patients with EHIT class 3 or 4. Rivaroxaban is an attractive option in the treatment of venous thromboembolic diseases due to the simplification of treatment.Case report: After successful ablation of the great saphenous vein (GSV) in a patient with complete insufficiency (Hach III) combined with sclerotherapy of superificial varicose veins of the calf the patient got a prophylactic anticoagulation with low-molecular weight heparin (LMWH) and compressions stockings grade II. Nevertheless we saw in the control-compression ultrasound after 7 days an asymptomatic EHIT class 1. Due the progression to EHIT class 3 after another seven days under watchful waiting we treated the patient with Rivaroxaban for 14 days. After the treatment we saw a complete resolution of the clot. Anticoagulant treatment and compression stockings (for three weeks after EVLT) were discontinued.

SummaryRadiofrequency endovenous ablation treatment is a safe, effective and durable technique for the treatment of great saphenous vein truncal incompetence. However, it is associated with relatively rare complications, such as ecchymosis, paresthesia, hyperpigmentation, phlebitis, haematoma, deep vein thrombosis and pulmonary embolism. Among these, aesthetic complications are the most frequent minor complications occurred after the procedure. This brief review defines and describes aesthetic complications after endovenous radiofrequency ablation of great saphenous vein and provides useful tips to minimize their incidence. Aesthetic complications can be avoided with a careful and accurate preoperative patient and vein evaluation, proper operative indication, adherence to procedure and device instruction for use and best postoperative management.

Saphenous reflux interferes with the physiological decrease in pressure and induces ambulatory venous hypertension. Elimination of reflux is achieved by flush ligation at the incompetent saphenofemoral junction and stripping of the great saphenous vein, which is the basis of the conventional surgical therapy. Endovenous ablative methods substitute stripping by thermal of chemical destruction of the saphenous trunk; they usually refrain from saphenofemoral junction ligation. Short-term and medium-term results up to 5 years, achieved after endovenous ablation without high ligation, are comparable with those after conventional surgery, which questioned the necessity to ligate the incompetent saphenofemoral junction. Nevertheless, clinical symptoms caused by recurrent reflux occur as a rule not earlier than 8 to 10 years after efficient abolition of reflux. Consequently, randomized studies with long-term follow-ups exceeding 10 years are necessary for trustworthy assessment whether it is justified to abstain from saphenofemoral junction ligation.

ZusammenfassungEinführung: Zur Behandlung der Stammvarikose mit dem VenaSeal™ Closure-System ist eine Narkoseform oder Tumeszenzanästhesie nicht erforderlich. Ebenfalls kann auf das Tragen von Kompressionsstrümpfen verzichtet werden. Über die Anwendung, erste Erfahrungen und 2 Jahresergebnisse wird berichtet.Material und Methode: In der Zeit von März 2012 bis Mai 2014 wurden 218 Patienten an 274 Stammvenen mit dem VenaSeal™ Closure-System therapiert. Doppler und Duplexuntersuchungen erfolgten nach 7 Tagen, 6 Wochen, 1 Jahr und 2 Jahren. Erhoben wurde die Verschluss- und Komplikationsrate, der visuelle analoge Schmerz-Score und der Venous Clinical Severity Score(VCSS).Ergebnisse: Nachuntersucht wurden 227 Stammvenen der Vena saphena magna (VSM) und 24 Stammvenen der Vena saphena parva (VSP). Die Verschlussrate der VSM betrug 99,5 % (n= 227) nach 7 Tagen, 96,5 % nach 6 Wochen (n= 172), 93,4 % nach 1 Jahr (n= 61) und 100 % nach 2 Jahren (n= 20). Die Verschlussrate der VSP betrug jeweils 100 % nach 7 Tagen (n= 24), 6 Wochen (n= 12) und nach 1 Jahr (n=4). Majorkomplikationen traten nicht auf. Als Minorkomplikationen traten nach Behandlung der Vena saphena magna inflammatorische Reaktionen bei 44 Beinen und Phlebitiden bei 32 Beinen auf. Der Pain Score entwickelte sich unter der Behandlung von 1,4 auf 1,5 (3. Tag), 2,1 (5. Tag), 1,6 (10. Tag), 0,2 (4 Wochen) auf 0,1 (6 Wochen). Der VCSS betrug präoperativ 4,4 und sank auf 2,9 (7. Tag), 2,1 (6 Wochen) auf 1,8 (1 und 2 Jahr)Diskussion: Die VenaSeal™ Closure-Behand-lung der Stammvarikose ist sicher und effektiv. Die Ergebnisse sind vergleichbar denen der thermischen Ablationsverfahren. Ohne die Anwendung der Tumeszenz-Anästhesie haben die Patientin deutlich weniger Beschwerden im Vergleich zu den thermischen Ablationsverfahren, sowohl während der Behandlung, als auch postoperativ.

SummaryFor years, measurement of the diameter of the great saphenous vein and, occasionally, the common femoral vein has been a component of many clinical studies on varicose vein treatment. There is consensus that the measurements should be conducted with the patient in the standing position and with a transverse view through the vein, but no standardised site of measurement of the venous diameter has yet been established. The shape of the great saphenous vein varies greatly at the saphenofemoral junction. Due to the curvature of the great saphenous vein, it is difficult to find a point at which the transverse view measured is at right angles to the course of the vein. According to the available data, the optimal site for measuring the great saphenous vein diameter is the proximal thigh. When measuring the common femoral vein, a transverse view immediately distal to the junction of the great saphenous vein is suggested and studies have also confirmed this.

Introduction: In 1998, radiofrequency ablation (VNUS Closure Plus™) was authorised in Germany and Europe for the treatment of superficial reflux. We participated in a clinical registry set up by the manufacturing company in 1998. The aim of this retrospective paper was to analyse the long-term results after radiofrequency ablation. Materials, methods and patients: In 1998, we operated on twelve patients (8 women, 4 men). In accordance with the concept of standard vein stripping surgery, all endovenous ablations were combined with crossectomy or ligature of the saphenopopliteal junction. Each vein was thermally ablated over its entire length and no tumescent anaesthesia was performed. The mean age of the twelve patients was 44.9 years. On ten occasions, the entire length of the great saphenous vein was treated, on one occasion the great saphenous vein at the level of the lower leg and on one occasion the entire length of the small saphenous vein. The mean duration of surgery was 80 minutes. Results: The follow-up period was 3 to 168 months, with a mean duration of 80 months. Six patients were followed up for longer than 120 months. In eight cases, follow-up examination was conducted using duplex ultrasound, in two cases using clinical examination and non-invasive measurement, in one case using clinical examination and in one case via a telephone interview. The most frequent perioperative complication, occurring in six cases, was hypaesthesia at the medial malleolus or lower leg. There was one case of perioperative thrombophlebitis of a lateral branch in the lower leg and one case of a third-degree thigh burn with subsequent infection of the great saphenous vein canal. No deep vein thrombosis or pulmonary embolism occurred in any of the operated patients. Of the eleven great saphenous veins treated, one had recanalised after 14 months, the others had closed or were no longer detectable on ultrasound. The small saphenous vein treated was also no longer detectable.In one patient, a major recurrence at the saphenofemoral junction and recurrent lateral branches in the thigh and lower leg were determined 168 months after surgery. No recurrent varicosis was determined in the other patients. Conclusion: Retrospective analysis shows that radiofrequency ablation leads to long-term elimination of the large or small saphenous vein, persisting for ten years and longer.

Calf muscle pump is the motive force enhancing return of venous blood from the lower extremity to the heart. It causes displacement of venous blood in both vertical and horizontal directions, generates ambulatory pressure gradient between thigh and lower leg veins, and bidirectional streaming within calf perforators. Ambulatory pressure gradient triggers venous reflux in incompetent veins, which induces ambulatory venous hypertension in the lower leg and foot. Bidirectional flow in calf perforators enables quick pressure equalization between deep and superficial veins of the lower leg; the outward (into the superficial veins) oriented component of the bidirectional flow taking place during calf muscle contraction is no pathological reflux but a physiological centripetal flow streaming via great saphenous vein into the femoral vein. Calf perforators are communicating channels between both systems making them conjoined vessels; they are not involved in the generation of pathological hemodynamic situations, nor do they cause ambulatory venous hypertension. The real cause why recurrences develop has not as yet been cleared. Pressure gradient arising during calf pump activity between the femoral vein and the saphenous remnant after abolition of saphenous reflux triggers biophysical and biochemical events, which might induce recurrence. Thus, abolition of saphenous reflux removes the hemodynamic disturbance, but at the same time it generates precondition for reflux recurrence and for the comeback of the previous pathological situation; this chain of events has been called hemodynamic paradox.

SummaryWe have performed a retrospective analysis of side-effect profile of endovenous laser ablation (EVLA) of great saphenous veins in patients operated on in general sedation or general/regional anesthesia with or without tumescence solution injection. The results confirmed our initial assumptions that omitting tumescence (and in addition, avoiding any external compression and cooling) may actually significantly reduce the incidence of moderate/severe postoperative pain and brusing without compromising closure rates. As these are probably caused by vessel wall perforations they seem to be more common in the tumescence cohort. The results are in line with recent basic research which showed that fiber tip centering may reduce perforations (easier to perform in vessels filled with blood), that blood itself does not either reduce or enhance laser‘s effect, and that various lasers over a wide range of wavelengths (from hemoglobin-absorbing to water-absorbing) have comparable clinical efficacy. Hence, omitting tumescence and external compression probably reduces the incidence of postoperative pain and brusing in patients treated with EVLA.

The objective of this paper is to review the major vascular complications of coronary artery bypass grafting (CABG). We discuss the risk factors, causes, diagnoses, treatment, and prevention of the major complications. A Medline search was done of the English-language literature from 1966 to the present. Key words used included coronary artery bypass grafting, vascular complications, stroke, intra-aortic balloon pump, and acute mesenteric ischemia. Further references were obtained through cross-referencing the bibliography cited in each work. Only first-level evidence was used in the paper. The major vascular complications of CABG are postoperative stroke, acute mesenteric ischemia, acute leg ischemia secondary to intra-aortic balloon pump use, harvest-site wound infections, and deep venous thrombosis. These complications have significant effects on the morbidity and mortality, length of stay, and hospital costs associated with CABG surgery. As a general rule, high clinical suspicion and the administration of early diagnostic and therapeutic techniques for established complications will greatly reduce the morbidity and mortality associated with the respective complications.

Popliteal venous aneurysms (PVA) are an uncommon but potentially life-threatening disease as they can be a source for pulmonary emboli (PE). We reviewed 21 patients (5 males, 16 females aged 33–79 years, mean age 60 years) with popliteal venous aneurysms treated between 1985 and 1998 in two centers. Nine aneurysms were discovered in patients with varicose veins, and 12 aneurysms were symptomatic: 50% presented with PE and 50% had thrombotic symptoms. The diagnosis of PVA was achieved by venous duplex imaging and phlebography: 85% (18/21) of the aneurysms were saccular and 43% (9/21) had an intraluminal thrombus. Surgical repair was performed by aneurysmectomy with venorrhaphy in 16 patients. Five patients had various procedures, including vein transposition (n=1), resection and end-to-end anastomosis (n=2), resection with interposition vein grafting using the greater saphenous vein (n=1) or superficial femoral vein (n=1). Two patients had a concomitant inferior vena cava filter placement. Mean follow-up was 53 months (range: 2 to 136 months). No operative deaths occured, and no patient had evidence of a recurrent PE. Postoperative thrombosis of the surgical repair developed in 3 cases. Patency was restored with anticoagulation therapy. Four complications (19%) included transistory nerve injury (n=2) and postoperative hematoma (n=2). Despite its rarity PVA should be ruled out in patients with PE and no other obvious embolic source or thromboembolic risk factors. Based on our experience and a review of the literature: (1) Surgical treatment is indicated in all symptomatic patients and tangential aneurysmectomy with lateral venorraphy is the recommended procedure; (2) Asymptomatic patients with saccular or large fusiform PVA should also undergo surgery because of the unpredictable risk of thromboembolic complications; (3) Asymptomatic patients with small fusiform and thrombus-free PVA may remain under close surveillance and surgery should be performed if thrombus is detected in the aneurysm and if thromboembolic complications occur. Although this policy has been advocated by some authors, it will have to be supported by other long-term observations.

Below-knee femoropopliteal and femorodistal bypass with nonautologous material shows poor patency rates, especially in multiple occlusions of the tibioperoneal vessels. Twenty-four patients underwent arterial reconstruction for limb salvage using the deep leg veins because the great saphenous vein was not available owing to previous operations. A follow-up period of forty-two months revealed an average bypass patency rate of 75%. During the control period all patients were prospectively investigated concerning changes in the venous system. The authors found only little changes in the venous system and no significant signs of venous insufficiency. The deep leg veins seem to be a valuable addition to arterial reconstructive surgery for limb salvage.

External valvuloplasty has been gaining in popularity as an alternative treatment for incompetent great saphenous veins. The procedure involves the implantation of a synthetic cuff around the saphenofemoral junction to compress the vein to a physiological diameter and thus restore the competence of the terminal and preterminal veins (1) (▶ Fig. 1). The important advantage of this method is that it preserves the great saphenous vein for possible use as a bypass graft in any vascular or cardiac surgery that may be necessary in the future, autologous veins being superior to artificial grafts for this purpose.

The physiopathology of venous symptoms, such as pain, leg heaviness or swelling sensations, in chronic venous disease (CVD) remains unclear. Localized release of proinflammatory mediators appears to play a key role but the presence of nociceptors sensitive to inflammatory mediators, such as unmyelinated C fibres, needs to be demonstrated. The present study included 10 patients with documented CVD who underwent surgery for saphenectomy. For each patient, five segments of the great saphenous vein were immunostained with anti-S100 protein and anti-CD45 to identify nerve fibres and inflammatory cells, respectively. Light microscopy was completed by electron microscopy. In all patients, S100 immunopositive nerve fibres and CD45 immunopositive cells were observed. Under an electron microscope, advanced signs of wall remodelling were systematically observed. The density of nerve fibres was low and variable from one sample to another. Unmyelinated C fibres were mainly located in the external part of the media and to a lesser extent in the internal part of the adventitia. Inflammatory cells, mainly histiocytes, were scattered in the media. Mast cells were observed in three patients. In conclusion, unmyelinated C fibres and inflammatory cells are present in the varicose saphenous vein wall. Their linked roles in symptoms of CVD should be further explored.

SummaryOur aim is to describe the results of a new short stripping technique for the treatment of the incompetent great saphenous vein (GSV) using a new developed surgical device. Patients, methods: 397 patients (498 legs) were treated with the InvisiGrip® Vein Stripper, which removes the GSV through a single groin incision, endovascular cutting and antegrade stripping by inversion. We reported the surgical success rate and postprocedural complications. Results: The mean age was 51 years, 74% were women. The success rate for removal of the GSV was 95%. The 23 failures were half patient related, half device related. In 82% of the strippings, one or two attempts were needed to successfully remove the GSV, which was done by invagination in 80%. Age, gender, BMI ≥30 kg/m2 and male GSV diameter were not associated with the number of attempts. Superficial wound infection, haematoma and temporary saphenous and femoral nerve injury occurred in 6 (1.6%), 0, 3 (0.8%) and 7 (1.9%) patients, respectively. Conclusion: The InvisiGrip® is highly successful for the removal of the GSV using short inverting stripping. Furthermore, it is simple, safe, associated with good cosmetic results and no preoperative selection of patients is necessary.

SummaryEndovenous bipolar RFITT (RadioFrequency-Induced ThermoTherapy) is a new approach for the treatment of varicose veins. RFITT provokes a thermal effect on the vein wall due to bipolar energy delivery. An alternating high frequency current creates heat in the vessel enabling a controlled tissue shrinkage. Results: Histological examination showed circular dissection of the intima with intramural bleedings and beginning condensation of fibrin thrombus because of the destroyment of erythrocyte cells. Perforation or carbonisation of the vein wall was not be detected. Conclusion: The histological and duplex sonographic pictures of veins after RFITT are comparable to those seen after the application of other endovenous procedures.

SummaryEndoluminal techniques such as laser therapy, radiofrequency therapy and sclerotherapy are increasingly replacing classic stripping for the treatment of incompetent saphenous veins. Interim results of the ongoing international, multicentre BRITTIV study to investigate the effectiveness and tolerability of the minimally invasive bipolar radiofrequency-induced thermal therapy (RFITT) are presented. Patients, methods: A flexible bipolar RFITT applicator is passed under ultrasound control into the affected vein of patients with varicosis of the great saphenous vein (GSV) or small saphenous vein (SSV). The vein is occluded by impedance-controlled release of radiofrequency energy as the RFITT applicator is slowly and smoothly withdrawn. The effectivness and tolerability of RFITT is checked over a one-year period by regular follow-ups. Results: To date a total of 345 saphenous veins (90% GSV, 10% SSV) in 271 patients (average age 50 years, 63% women, mean CEAP score 2.8) have been treated with RFITT in eight European hospitals. 72% of patients underwent general anaesthesia (18% spinal, 11% local) and tumescent anaesthesia was also used in 83% of the veins (mean length 45 cm). The average application time was 1.4 s/cm with a mean power output of 24 Watt. At the interim analysis after an average follow-up of 103 days, 90% of 335 treated veins were occluded. Differential analysis showed that partial (P) and complete (C) recurrences occurred significantly less often when longer application times had been used, whereby complete recurrences showed a greater reduction in frequency than partial. The total recurrence rate with an application time < 1 s/cm was 22% (P = 10%, C = 12%); with an application time between 1.0 and 1.4 s/cm it had already fallen to 9% (P = 6%, C = 3%) and with a time greater than 1.4 s/cm it was only 4% (P = 3%, C = 1%). According to subjective pain assessment on a visual analogue scale (VAS) of 0 to 10 (corresponding to no pain up to the strongest conceivable pain), by the first day after treatment already 74% of those questioned had only slight remaining pain or none at all (VAS 0–2). This generally low subjective pain sensation continued to fall at subsequent followups and at the 6-month follow-up, 99% of patients reported a VAS score of 0. Nearly all patients (99%) were satisfied with the treatment and would recommend it to others. Conclusions: With the same power output, even a minor increase in the application time to more than 1.4 s/cm can markedly reduce recurrence rate. In summary, the ongoing BRITTIV study illustrates the potential of RFITT for use in phlebology as it combines a spatially-defined obliteration of incompetent saphenous veins with overall moderate side effects and impressive results.

SummaryTumescent anaesthesia is a widley accepted anaesthetic procedure for the surgery of varicous veins. In our institution tumescent anaesthesia is regularly combined with femoral nerve block or sciatic nerve block for primary operations of the great saphenous vein (GSV) or small saphenous vein (SSV).This combined procedure is described. Retrospective data of 154 operations of the GSV and of 27 operations of the SSV are presented. We used 9.5 mg/kg body weight of prilocain for operations of the GSV and 8.6 mg/kg body weight for operations of the SSV. No serious complications occurred.

A 22-year-old man with movement-dependent knee-joint pain was operated on for patellar chondroplasia and meniscal dysplasia after two previous arthroscopic removal of free joint bodies had failed to bring relief. A few months after the operation the same leg had become swollen with signs of venous congestion, long saphenous vein varicosity and traumatic pretibial crural ulcer. The long saphenous vein was partially excised. 18 months after the arthrotomy there was clinical and colour-Doppler evidence of an arteriovenous fistula with false aneurysm in the region of the popliteal artery as cause of the venous congestion. The ulcer healed completely after ligation of the fistula and excision of the false aneurysm. --Arterio-venous fistula should be included in the differential diagnosis as a possible cause of postoperative swelling of a limb.

SummaryThe pathogenesis of premenstrual tension syndrome is not fully understood. It has been hypothesized that the interaction between sex hormones and target organs is the key event in its pathogenesis. Aim: The purpose of the study was to examine the differences in the prevalence of smooth muscle cells with sex hormones receptors in varicose veins of women with and without premenstrual tension syndrome (PS). Patients, methods: Samples of great saphenous vein were obtained from 50 women during varicose vein surgery. They were divided into group I (20 women with clinically diagnosed PS) and group II (30 women without PS). Estrogen and progesterone receptors were detected with an immunohistochemical method. Superficial densities of smooth muscle cells positive to estrogen and progesterone receptors were analyzed with densitometric program IM-AN and automatic image analyzer Magicall. The results were compared with t-Student test. Results: There were no differences in superficial density of smooth muscle cells positive to estrogen receptors between the groups. In contradiction to this, superficial density of smooth muscle cells positive to progesterone receptors was higher in group with PS than in patients without, 343 (±171) and 240 (±123), respectively. The difference was statistically significant (p < 0.05). Conclusion: The amount of cells with sex hormone receptors, not the level of hormones, could play a role in PS pathology. Our results show that progesterone is more important than estrogen in effector organs.

SummaryWe present two case reports concerning patients who had to undergone surgical treatment according tp the diagnosis of thrombophlebitis with insufficiency of the greater saphenous vein and putative encapsulated haematoma in the lower left leg area. During the operation we found tumours with urgent suspicion of malignancy. The histological examination revealed the diagnosis of mesenchymal chondrosarcoma and malignant peripheral nerve sheath tumour which are extremely malignant, but very rare neoplasmas with unfavourable prognosis. Conclusion: Since both types of tumours are often located below the knee, phlebotomists and vascular surgeons should take them into account as differential diagnosis.

BACKGROUND We sought to determine whether the postoperative and midterm outcomes of minimally invasive and endoscopic great saphenous vein harvesting are comparable. METHODS From February 2004 to September 2006, 120 patients underwent minimally invasive vein harvesting, and subsequently 150 patients had endoscopic vein harvesting for CABG. Patients were evaluated prospectively for wound-healing disturbances, residual leg oedema, pain intensity and saphenous neuropathy on the 7th postoperative day and after 3 months. RESULTS Both harvesting techniques were associated with a low incidence of wound-healing disturbances; nevertheless, minimally invasive vein harvesting was associated with a significantly higher incidence of residual oedema (28 % vs. 13 %; P < 0.05), (19 % vs. 6 %; P < 0.001), pain (20 % vs. 9 %; P < 0.05), (10 % vs. 6 %; P < 0.05), and saphenous neuropathy (23 % vs. 7 %; P < 0.001) (14 % vs. 3 %; P < 0.001) during follow-up on the 7th postoperative day as well as 3 months after surgery, respectively. Mean harvesting time (40.6 +/- 15.5 vs. 43.9 +/- 10.2 min; P = 0.09), conversion rate (3 % vs. 2 %; P = 0.71), and injury per conduit (0.3 +/- 0.2 vs. 0.3 +/- 0.1; P = 0.91) were comparable for both groups. CONCLUSIONS Endoscopic vein harvesting seems to be superior to minimally invasive vein harvesting in terms of a significant reduction of residual leg oedema, pain intensity and particularly saphenous neuropathy in the postoperative and midterm follow-up.

Summary Objective: The goal of the study was to assess the effectiveness and patient tolerability of single-session, sonographically guided, transcatheter foam sclerotherapy and to evaluate its economic impact. Patients, methods: We treated 20 patients with a total of 22 varicoses of the great saphenous vein (GSV) in Hach stage III-IV, clinical stage C2-C5 and a mean GSV diameter of 9 mm (range: 7 to 13 mm). We used 10 ml 3% Aethoxysklerol®. Additional varicoses of the auxiliary veins of the GSV were sclerosed immediately afterwards. Results: The occlusion rate in the treated GSVs was 100% one week after therapy as demonstrated with duplex sonography. The cost of the procedure was 207.91 E including follow-up visit, with an average loss of working time of 0.6 days. After one year one patient showed clinical signs of recurrent varicosis in the GSV; duplex sonography showed reflux in the region of the saphenofemoral junction in a total of seven patients (32% of the treated GSVs). Conclusion: Transcatheter foam sclerotherapy of the GSV is a cost-effective, safe method of treating varicoses of GSV and broadens the spectrum of therapeutic options. Relapses can be re-treated inexpensively with sclerotherapy.

Colour coded Doppler sonography can be very helpful for the diagnosis of haemorrhagic infarction of the brain parenchyma, cerebral venous thrombosis and arterio-venous malformations of the brain. Intracranial haemorrhages into the brain parenchyma are caused by the compression of the subependymal and terminal veins which impede the venous drainage from the white matter. Haemorrhage of the basal ganglia is highly suspicious of cerebral venous thrombosis especially of the deep venous drainage. Unilateral occlusion of only one internal cerebral vein causes unilateral haemorrhage, bilateral thrombosis of both internal cerebral veins as well as occlusion of the great vein of Galens or the straight sinus causes bilateral haemorrhage of the basal ganglia as well as ventricular haemorrhage and haemorrhagic infarction of the white matter. The most common arterio-venous malformation of the brain is AV-malformation of Galens's vein. Sonographically, a pulsating cystic structure behind the 3rd ventricle can be shown. Colour coded Doppler sonography demonstrates the vascular nature of the cyst. Doppler sonography can show the feeding arteries, most frequently the posterior choroidal arteries and the venous drainage by the straight sinus.

Dopplersonographic flow measurements in the intracranial veins of infants are not often applied. For the understanding of intracranial pathology such as vascular malformations, intracranial hemorrhagic infarction and venous thrombosis, a thorough understanding of the anatomical position and of the normal flow profiles and flow velocities in intracranial veins is essential. We describe the normal anatomic course of the cerebral veins and their flow profiles and flow velocities in infants. In sagittal sections, the following veins can be shown by colour coded Doppler sonography and measured by pulsed Doppler sonography: The superior and inferior sagittal sinus, and the straight sinus as well as the internal cerebral vein, the vein of Galen and the thalamostriatic veins. In coronal sections, the medullary and subependymal veins, the terminal veins, the internal cerebral veins, the great vein of Galen, the superior sagittal, straight and transverse sinus can be demonstrated and measured.

Aneurysms of the popliteal vein without symptoms are a rare clinical finding. Most patients presented with symptoms of thromboembolism. Because of this nobody knows the exact incidence rate of this occurrence. We describe the case a 49-year-old female who presented with popliteal fossa pain. A popliteal venous aneurysm was detected by ultrasound and has now been observed for 42 months without complications, therapy, and symptoms. Literature on the subject, mostly case reports, is rare and the treatments used differed greatly. Most proposalstry to treat asymptomatic patients suffering from saccular aneurysm with parietal thrombi and symptomatic patients are treated by medical or better surgical intervention. The remainder of asymptomatic patients can be kept under observation by means of color Doppler and duplex sonography.

The vascular anastomoses are usually made with sutures. Some mainly experimental studies have been published about a new method of doing the vascular anastomoses with metal clips. We studied the suitability of vascular closure staple (VCS) clip applier system for making the anastomoses in femoropopliteal and femorotibial arterial reconstruction. During an 11-month period, VCS clips were used in 17 out of 27 patients who were operated due to severe claudication or incipient gangrena of the foot. Altogether 26 anastomoses were made with VCS clips using either great saphenous vein or PTFE graft. The making of anastomosis was easy and reliable. No postoperative bleeding was noticed. All anastomoses were patent 4-6 weeks postoperatively studied by palpation and measured by ankle brachial pressure index (mean 0.96). In Duplex Doppler examination all studied patients had well patent anastomoses on an average 11 months after the operation. With VCS clip applier system, it is possible to do anastomoses in arteriosclerotic arteries like in femoropopliteal reconstructions. This method helps making reliable anastomoses more easily.

SummaryThere are no cases reported about endovascular varicosis therapy having an impact on the erectile function of the man. This case reports’ patient had a stronger erection in the area of the glans penis after he underwent endovenous lasertherapy of the great saphenous vein.This effect could also be explained with the anatomy of the veins because some of the blood of the penis is drained by the external pudendal vein which leads into the saphenofemoral junction. If there is a manipulation on the veins of the saphenofemoral junction it might have an impact on the drainage of the penis.

A 56-year-old male patient initially presented in our clinic in January 2008 with visible skin changes and tired, heavy legs. Ultrasound examination showed bilateral insufficiency of the great saphenous vein (GSV), grade IV according to Hach, with bilateral varicosis of the lateral saphenous branches in the lower legs with grade II chronic venous insufficiency (CVI) and CEAP 4a without insufficiency of the deep veins. Secondary findings were arterial hypertension, appendectomy in 1965, tonsillectomy in 1967, reconstruction of the right cruciate ligament in 1990, partial rightsided meniscal resection in 1999 and history of gastric ulcer. As treatment measures, we recommended the continuous wearing of class 2 compression stockings and surgical treatment of the varicose veins in stages. The patient presented for the second time almost exactly 5 years later in January 2013. Findings had changed only minimally and the patient had recently suffered from thrombophlebitis of the right GSV, with occlusion extending from the mid-calf to mid-thigh. Surgical treatment was again recommended, primarily on the left side. The patient was no longer wearing the compression stockings. Therapy

Reasons why venous tracer infusion with arterial sampling [(v-a) mode] has advantages compared to arterial infusion and venous sampling [(a-v) mode] for studies of blood lactate kinetics are presented. Arterial tracer infusion can result in biased tracer input due to streaming and unequal blood flow distribution. The procedure is impractical for human studies. Venous sampling from the jugular, or any other peripheral or great vein, provides a sample which may, or may not represent mixed venous systemic blood, which exists only in the pulmonary artery. Venous sampling will not represent cardiac lactate metabolism because the coronary arteries drain into the coronary sinus. Venous sampling, as well as pulmonary artery sampling, will also ignore lactate metabolism in the lungs which drain into the left atrium from bronchial and pulmonary circulations. Turnover rates calculated from either venous or arterial specific activities underestimate true tissue turnover. Correction for either measurement depends on good estimates of blood flows to lactate exchanging and non-exchanging tissue. Equilibration between lactate and pyruvate pools does not invalidate the use of tracers to measure lactate turnover. The (v-a) mode with venous infusion and arterial sampling has advantages for lactate tracer studies.

The veno-accompanying artery fasciocutaneous (VAF) flap and veno-neuro-accompanying artery fasciocutaneous (V-NAF) flap are fasciocutaneous flaps receiving arterial blood supply from accompanying arteries of the cutaneous vein and nerve (Nakajima, 1999). These skin flaps can cover skin defects of the extremities as pedicle flaps. These authors reported the results of these flaps used to cover skin defect of the leg. Since 1996, 17 flaps were used in 17 patients. The mean age of 14 men and 3 women was 42 years (range: 3 to 71 years). Cases involved skin defects in 6 patients, traumatic bone and skin defects in 5, and skin defects after tumor resection and after contracture release in 3 patients each. Four patients had combined osteomyelitis and were treated simultaneously with antibiotic-impregnated bone cement. The size of the skin defect ranged from 4 cm × 3.5 cm to 15 cm × 8 cm. The sural or saphenous nerve was used in V-NAF flaps. Currently, the authors spare these nerves, especially the saphenous nerve, in the proximal leg because it runs under the fascia and makes less of a contribution to the blood supply to the leg. There were 13 flaps containing the small saphenous vein and 4 flaps containing the great saphenous vein. Five proximally-based flaps were used to cover proximal skin defects, as proximal as the popliteal fossa and the prepatellar region. Twelve distally-based flaps were used to cover distal skin defects, as distal as the stump of Chopart amputation. Follow-up ranged from 1 year to 6 years (mean: 2 years). All flaps survived completely. The donor sites of these flaps were closed primarily in 6 and with a skin graft in 11 cases. All osteomyelitis cases healed without any problems. Skin defects exposing bone in the leg and ankle are difficult to treat. Free vascularized flaps used to be required in many cases. However, free flap transfer may be difficult in elderly patients or in patients having disease or damage to major arteries of the leg. The VAF and V-NAF flaps are pedicle flaps, relatively easy to dissect and with no need to sacrifice the major arteries of the leg. They are useful for covering skin defects of the leg and ankle.

A method for demonstrating the great saphenous vein is described which allows one to demonstrate it throughout its length, and to judge its patency without screening it. The method is suitable for examining the vein before removing it for arterial reconstruction, or for use as a by-pass.