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In routine clinical work, the dosage of direct oral anticoagulants for long-term maintenance therapy after acute deep vein thrombosis and pulmonary embolism is often made on an individual basis. As two doses are available for the preparations apixaban and rivaroxaban and no separate indication spectra have been specified. The working group of practising vascular physicians and surgeons in Germany has therefore developed this position paper. Patients with a clearly identified and temporary trigger factor for venous thromboembolism (e.g. trauma, operation, acute internal disease, oral contraception or pregnancy or isolated thrombosis of veins in the lower leg have a lower risk of recurrence and are generally not given permanent anticoagulation. If there is a high risk of recurrence with unchanged trigger factor (e.g. active malignancy, unambiguous antiphospholipid syndrome or deficiency of a clotting factor, such as Protein C, Protein S or antithrombin with a positive family history of venous thromboembolism, first occurrence of a pulmonary embolism, multiple recurrence of VTE) prolonged maintenance therapy is indicated, unless this is contraindicated by a very high risk of bleeding. For all patients with former VTE and whose anticoagulation phase has in principle been completed, prolonged prophylaxis can be continued, as these patients too are at increased risk of VTE., Competing Interests: Die Autoren haben in unterschiedlichem Ausmaß honorierte Vorträge für die Firmen Pfizer, Bayer, Daiichi Sankyo, Böhringer Ingelheim, Sanofi, Aspen und GSK gehalten und an Zulassungsstudien teilgenommen., (Georg Thieme Verlag KG Stuttgart · New York.)

Unlabelled: Thrombophlebitis (TP) of the superficial venous system is associated to a high percentage with deep venous thrombosis (DVT). References in literature vary between 5 and 65 %, pulmonary embolisms (LE) were described in up to 33 %., Patients: In a retrospective study, 114 patients who had presented themselves with a TP of the superficial venous system between January 1 (st) and December 31 (st) 2004, were analysed in our institution. 50 % (n = 57) exhibited a TP in side branches of the superficial venous system. 19.3 % (n = 22) showed a TP of the great saphenous vein (GSV) of the calf or of the small saphenous vein (SSV) distally, in 28.1 % (n = 32) the GSV or SSV were affected at the thigh or proximally or in total length, 3 patients (2.6 %) exhibited a TP of the arm vein. 11 patients (9.6 %) showed a concomitant DVT. The frequency of DVT depended on the localisation and extension of the TP, and also on additional basic and acute risks for DVT. The incidence of a concomitant DVT was 5.2 % when side branches were affected and amounted to 15.6 % with TP in the area of the GSV or SSV. With varicosis as single risk factor, the frequency of a concomitant DVT was 6 %, varicosis combined with further risks showed a DVT frequency of 15.4 %., Results: All patients were treated with low molecular weight heparin either with prophylactic or therapeutic dosage, depending on localisation, extension and concomitant diseases. 10.5 % of the patients (n = 12) had to undergo urgent surgery with ligation of the sapheno-femoral junction or popliteal junction, if the TP had reached the junction into the deep venous system. By this therapy, we had not to observe any additional DVT. In 9 cases, an extension, respectively a recurrence of the TP could be observed. In each of these cases the dosage of the LMWH had not been adapted to the concomitant risks or had been terminated too early., Discussion: TP of the superficial venous system should be considered and treated as DVT. Consequent anticoagulation is needed, surgery should be performed when the TP reaches the junction into the deep venous system. The duration of the anticoagulation is not quite clear, but is carried out in our institution for three months with therapeutic intention.

The principles of modern varicose vein surgery are based on the interruption of the cranial and distal points of venous insufficiency. Especially due to the rise of alternate surgery procedures, we have scrutinized our results of varicose vein surgery. In a retrospective analysis, the results of those patients (pat.) who underwent venous surgery in our institution in 1995 were analysed. In 1995 we performed 1 575 varicose vein operations (n = 1 019 pat., 16.8 % male, 83.2 % female). 63.5 % were on an outpatient basis. During a follow-up period of 4 to 66 months (av. 38 months) the patients were re-examined, 481 (47.2 %) by Duplex sonography, 94 (9.2 %) by clinical examination alone, from 103 (10.1 %) information was obtained through a written inquiry. 341 pat. (33.5 %) had just perioperative follow-ups. We didn't find any signs of varicosis in 301 pat. (33.3 %). Minor side branches could be detected in 515 pat. (56.8 %). In 90 pat. (9.9 %) a clearly visible varicosis could be seen. Based on the results of the Duplex examinations, 86 % of the pat. showed no recurrence after ligation of the sapheno-femoral junction and stripping of the LSV, the results after stripping of the short saphenous vein were similar. Analysis of the inquiry forms concluded that 62.3 % of the pat. were satisfied with surgery and the results. The results of the standard varicose vein surgery are satisfactory regarding recurrence rate and patient satisfaction. Our results are comparable to those published in prospective randomised studies. Alternate procedures, for example the CHIVA method, have still to proof their efficiency, especially in view of long-term results.

Over the past years out-patient operations of varicose veins have become increasingly accepted. In the year 1998 the number of patients treated for long saphenous vein varicosis on an outpatient-basis has risen to 66,922. For the individual risk assessment of the patient the ASA-classification is proven. ASA-class I and II patients may be considered for out-patient treatment. 98.2% of our patients that were operated upon 1995 on an outpatient-basis were classified as ASA I or II. Beside the risk assessment the extension of the disease should determine the indication for outpatient or inpatient treatment. During the year 1995 the majority of operations were performed for long or short saphenous vein varicosis (51.3% in the outpatient group, 61.9% in the inpatient group). But the percentage of isolated treatment of sidebranches and perforating veins was much higher in the outpatient group with 30% in comparison to the inpatient group with 3.4%. Under these conditions outpatient varicose vein surgery can be carried out with good result and a low complication-rate. In our outpatient group a deep vein thrombosis occurred in 0.03%, in other outpatient centers the incidence of deep vein thrombosis was reported with 0.08%. Wound infection was seen in 0.49%, a bleeding complication in 0.16% of the patients.

Sclerotherapy is in general a very safe method for the treatment of teleangiectasias and reticular varicose veins done by an experienced therapist. The complication-rate is very low, with the use of Polidocanol the rate of skin-necrosis ranges between 0.001 and 0.2%, the incidence of superficial thrombophlebitis is 0.08%, the incidence of an allergic reaction is reported with 0.2%. The sclerotherapy of large perforating veins and the long or short saphenous veins is controversially discussed. The results of prospective randomized studies show better results with operative treatment in comparison to sclerotherapy. The recurrence-rate of sclerotherapy of the long saphenous vein varies between 22 and 37% after 3 years, between 40 and 70% after 5 years and 94% after 10 years. Before starting the sclerotherapy the extension of the varicose vein disease should be diagnosed correctly. The diagnosis can be obtained with duplex-ultrasound, that gives either functional and morphologic information about the deep and superficial venous system.

In a retrospective analysis of 115 patients who underwent a coronary reoperation between 1984 and 1989, we studied the influence of age and other risk factors on the perioperative morbidity and mortality and on the long-term results. The mean age of the population was 59.4 years, 55 patients were below 60, 52 between 60 and 70 and 8 patients over 70 years, respectively. The distribution of risk factors was similar to other populations suffering from coronary heart disease. The mean time between first and second coronary operation was 7.1 years. Complete revascularisation at the reoperation could be achieved in only 20.9% (n = 24) of the patients. A mean of 1.9 vein grafts were implanted. The perioperative mortality (within 30 days) was 5.2% (n = 6) for the whole group, whereas the highest mortality rate could be observed in the patients aged over 70 with 25% (n = 2). The incidence of perioperative complications was also higher in the elderly patients, comparing them to the whole group. Mean follow-up time was 39 months. During follow up 14 patients (12.4%) died, most of the deaths were cardiac related. The cumulative survival rate was 91% after one, 90% after three, and 88% after five years. We found no statistically significant differences in the survival rates and the myocardial infarction rates regarding the different age groups. The exercise capacity and functional status at the time of follow up were quite acceptable.(ABSTRACT TRUNCATED AT 250 WORDS)