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Background. Osteoarthritis (GA) in patients with varicose veins of the lower limbs (VVLL) is more common than in the population, and degenerative changes in the knee joints deteriorate clinical course of such vascular pathology. The purpose and objectives: to assess the effect of GA on the course and efficiency of surgical techniques in VVLL treatment, highlight prognostic criteria. Materials and methods. The study included 302 patients (227 men and 75 women aged 29–72 years old), 16 % of which had previous phlebothrombosis and II, III, IV, V and VI classes of venous insufficiency occurred in 10, 14, 37 16 and 23 %, respectively. 263 patients underwent endovenous laser coagulation, and 39 had the traditional phlebectomy and ligation of perforating veins. Results. GA was diagnosed in 18 % of patients with VVLL, more common in men of older age, and involved the great saphenous vein with gate extension and was combined with arteriosclerosis of the lower limbs vessels, which was accompanied by more severe classes of venous insufficiency, while the clinical laboratory manifestations of varicose veins is influenced by disease stage, changes of meniscal horns, the presence and severity of subchondral sclerosis, osteocystosis, synovitis, Baker’s cysts, intra-articular Shtaydi and Hoff bodies. The effectiveness of the results of surgical treatment in patients with GA was worse, while full vein occlusion in a month after the endovenous laser ablation observed occurred in 2.8 times less cases, the number of complications was 7.3 times more frequent that was defined by subchondral sclerosis, osteousuras, Baker’s cysts and intra-articular Hoff’s bodies. Conclusions. The presence of GA is a risk factor for more severe clinical course in leg varicose veins, a negative prognostic negative factor for surgical treatment of the disease and complications number.

Background. Type 2 diabetes mellitus (DM2) is a risk factor for arteriosclerosis of the lower extremities, and the relationship with the state of the feet venous vascular territory remains insufficiently studied, the effectiveness of surgical treatment of patients with varicose veins is not defined. Objective: to analyze the clinical course of foot varicose veins and the effectiveness of medical measures on the background of DM2. Materials and methods. The study included 302 patients (227 men and 75 women aged 29–72 years old), 16 % of which had previous phlebothrombosis and the prevalece of II, III, IV, V and VI class of venous insufficiency was 10, 14, 37 16 and 23 %, respectively. 263 patients underwent endovenous laser coagulation, and 39 — the traditional phlebectomy and ligation of perforating veins. Results. Among the examined patients with varicose veins of lower extremities DM2 was diagnosed in 9 % of cases, more often in males and elderly patients on the background of atherosclerosis of the foot vessels (iliac, femoral, tibial, popliteal artery), which was accompanied by more frequent involvement of the great saphenous vein in the process and its gate extension, the prevalence of severe grades of venous insufficiency, significantly worse the results of surgical treatment of varicose veins and greater frequency of complications, despite more frequent using of rivaroxaban and low molecular weight heparins, and the effectiveness of endovenous laser ablation after four weeks of its implementation is inferior to that in the group without DM2, while glycemic index inversely correlated with the surface tension of the venous blood, which has prognostic significance in the context of future medical interventions. Conclusions. The presence of DM2 is a risk factor for more severe feet varicose veins, is a negative predictive factor in the effectiveness of surgical treatment of the disease and the complications number.

Background. In some regions, up to 1/4 of the adult population suffer from varicose vein disease (VVD) of the lower limbs, and its incidence increases every year. A risk factor for the prevalence and severe course of VVD is type 2 diabetes mellitus (DM2). It is believed that every fifth patient with trophic ulcers of the skin of the lower legs suffers from DM2 due to VVD. Such comorbid pathology causes significant medical, social and economic damage to sick people and the society as a whole. The purpose was to study the nature of the course of VVD and comorbid diabetes, to assess the clinical and pathogenetic significance of the changes in carbohydrate metabolism. Materials and methods. Under the survey, there were 162 patients with VVD (19 % of men and 81 % of women with the average age of 50 years) among whom the ratio of classes II, III, IV, V and VI of venous insufficiency was 1 : 1 :3 : 1 : 2. DM2 occurred in 14 % of cases while the distribution of mild, moderate and severe forms of the disease was 1 : 2 : 4 and the ratio of the phases of compensation, subcompensation and decompensation was 1 : 4 : 6. In the blood from the cubital vein and the affected vein of the lower extremities, the levels of glucose, glycosylated hemoglobuin, insulin, C­peptide, fructosamine were studied by biochemical and enzyme immunoassays (devices Olympus­AU­640, Japan, SF46, Russia, PR2100, Sanofi Diagnostics Pasteur, France, BIO­RAD­D10, USA). Results. VVD is accompanied by the changes in carbohydrate metabolism that has gender characte­ristics and is associated with the severity and clinical manifestations of comorbid DM2 (angiopathy, neuropathy, arthropathy), local production of fructosamine by the affected vein, at the same time determining the severity of venous insufficiency, it depends on the state of the varicose vein (trunk lumen, previous phlebothrombosis) and arterial vascular system. Conclusions. VVD and DM2 aggravate the course of each other, and local changes in carbohydrate metabolism are involved in pathogenetic constructions of venous pathology.

The objective:an identification of changes and reorganization of structural elements of the venous wall, their correlation with cancer processes in the organism; the establishment of the relationship between structural changes in the wall of the venous vessels and thrombosis, with the following complications; the determination of the necessity of the preventive measures to avoid complications. Materials and methods.Histological, submicroscopic and polarization data of the research of the veins of the hind limbs of 12 sexually mature nonlinear male rats weighing 170–180 g on the 30th day of chronic neoplastic intoxication were analyzed. A retrospective analysis of the autopsy protocols of cancer patients (n=54), the largest incidences – pulmonary embolism, during 2014-2018 in the Ternopil Regional Clinical Oncology Center was performed. The average age of women who died was 61.93±1.51 years and 62.44±2.61 years – for men. Results.As a result of morphological examination of the veins of the hind limbs of rats with experimental neoplastic intoxication revealed mainly submicroscopic reorganization of endothelial cells and their desquamation, as well as platelet aggregation that can be one of the links in the pathogenesis of thrombosis. According to a retrospective analysis of the autopsy protocols, the proportion of pulmonary embolism was higher among women (61.1 %) than men (38.9 %). The structure of oncopathology in this group of patients: bronchial and lung cancer (18.5 %); neoplasms of the uterine body (22.2 %); rectum cancer (13.0 %), colon cancer (7.4 %), rectosigmoid junction cancer (5.6 %); bladder cancer (9.3 %); gastric cancer (7.4 %); ovarian cancer (7.4 %); prostate cancer (5.6 %); thyroid cancer (1.8 %); pancreatic cancer (1.8 %). In all cases of autopsy phlebothrombosis of the deep veins of the leg and thigh with impaired blood flow caused by occlusion by blood clots of various manifestations of the structural organization was revealed. In five cases, fresh red blood clots were found, which were closely connected with the intima by fibrin threads, in five other cases – red blood clots were freely located in the lumen of the vein, swelling of all layers of the vein, fibrous structure and diffuse neutrophil infiltration were found. In the remaining 44 cases, vein occlusion was detected by already organized thrombi with signs of fibrosis, recanalization, and revascularization. Conclusions.The study of the morphology of rat hind limb veins with experimental neoplastic intoxication mainly revealed changes in the shape, structure and function of endotheliocytes, their desquamation and changes in all three layers of the venous wall as well as platelet ligation. The relationship between the presence of changes in the venous wall as a result of cancer and the formation of thrombosis was found. The number of thromboembolic complications emphasizes the necessity to prevent thrombosis in cancer patients.

Annotation. The goal of this study was to investigate the characteristic histological and morphological signs of changes in the venous wall as one of the main pathogenetic links of thrombosis in oncological pathology. Assessment of these changes is necessary to understand the process of occurrence and prevention of thromboembolic and thrombotic complications in patients with oncological diseases. Histological, submicroscopic and polarizing materials of hind limb veins of 11 mature nonlinear male rats weighing 170-180 g on day 30 of chronic neoplastic intoxication complicated by deep limb vein thrombosis were studied. It is established that experimental neoplastic intoxication in rats on histological examination was accompanied by the development of submicroscopic reorganization of endotheliocytes and their desquamation, platelet ligation as one of the causes of future thrombotic complications. Thus installed the negative effect of long-term neoplastic intoxication on the cells and all layers of the venous vascular wall as well as on the blood forming elements was studied. A close connection between the presence of the obtained changes against the background of oncological diseases and the development of such thrombotic complications as phlebothrombosis, pulmonary embolism and thrombophlebitis has been established. The development of complications shows that the prevention of thrombosis is an important component of conservative therapy of cancer patients, to prevent the development of lethal outcomes. High incidence of PE, deep vein thrombosis and thrombophlebitis in the superficial venous system emphasizes the use of preventive means of conservative treatment of cancer patients to prevent these complications, resulting in a high mortality rate. The study of morphological changes of the venous wall under the influence of chronic neoplastic intoxication in experimental conditions allows to carry out a detailed analysis of possible complications.

Objective: To evaluate the effect of physical methods on the prevention of venous thrombosis in patients with peripherally inserted central catheter (PICC). Methods: Randomized controlled trials meeting the inclusion and exclusion criteria were retrieved from the following databases: Cochrane library, Pubmed, EMbase, Web of science, Ovid, CBM, CNKI, Wanfang, VIP, then Review Manage (RevMan) 5.3 software was used for data analysis. Results: A total of 24 RCTs including 3496 patients were analyzed in the study. The results of meta-analysis showed that various forms of upper limb movements could effectively decrease the incidence of venous thrombosis in the patients with PICC [RR = 0.23, 95% CI (0.16, 0.33), P MD = 1.65, 95% CI (1.19, 2.11), P < 0.01]. Conclusion: Upper limb movements can effectively decrease the incidence of phlebothrombosis and improve the mean flow velocity of basilic vein in the patients undergoing PICC. Other forms of physical prevention methods need to be further studied due to insufficient sample size.

Objective: to study the peculiarities of the state of the lower extremities venous system in patients with complicated diabetic foot syndrome (DFS). Materials and methods. The study group – 106 patients with type 2 diabetes mellitus (DM) and purulent-necrotic complications of DFS treated in the surgical department of the St. Petersburg State Medical Academy in 2009-2014. 30 preparations of the lower extremities obtained as a result of amputations in patients with purulent-necrotic complications of DFS and from corpses after autopsy. Conducted a macroscopic study of the lower extremities veins with a visual assessment of the changes and microscopic examination with the staining of histological preparations with hematoxylin and eosin, according to Van Gieson and Masson; ultrasound duplex examination (ultrasound) of the lower extremities veins in patients with DFS according to the standard protocol. Results. Macroscopic evaluation in 90.0 % of cases revealed an excess of extracellular fluid (edema) of the extremities tissues. An analysis of the ultrasound findings of the lower extremity veins demonstrates the presence of lymphostasis in patients with diabetes in 83.0 %. In the overwhelming majority of preparations of vessels of the extremities with DFS (97.0%), a segmental expansion of the venous lumen was detected. Such a change can be the cause of cases detected during ultrasound in 60.0% and 73.0%, respectively, of dilatation of the veins and valvular insufficiency. In both morphological and ultrasound studies in no more than 15.0% of cases, the expansion sites were in the superficial veins, and fragments of an increase in the diameter of the lumen of the deep veins were found in 60.0% of patients, which demonstrates the likely difference in the nature of changes in the veins in diabetes and with varicose veins. In macroscopic and then histological studies, pronounced intramural and parabasal fibrosis of venous vessels was found in 37.0 0% and in 67.0 0% of cases, respectively. A rather specific feature to characterize the lesion of the venous system in diabetes is an increase in sonographic density of paravasal tissues, especially around the veins of the deep system (about 35.0% of observations). The findings of the ultrasound study describe the incompressibility of a vein or a decrease in its elasticity in the absence of data on the presence of a local thrombus, signs of current or resolved phlebothrombosis in 29.0% of cases in patients with DFS, which exceeds the general population frequency of this pathology even by the highest estimates of researchers. A morphological study of blood clots in venous vessels was found in 57.0% of observations, which may be due to the clinical insignificance or difficulty of visualizing small parietal thrombi and blood clots of small diameter venous vessels, but it confirms both complex disorders of the hemostatic system in diabetes and changes in venous walls predisposing to intravascular thrombosis. Conclusion. Patients with purulent-necrotic complications of DFS in most cases have signs of damage to the lower extremities venous vessels, it is specific. Standard duplex ultrasound can detect these changes.

Introduction. The peculiarity of the clinical course of renal cell carcinoma is its propensity to venous distribution with the formation of a implantation thrombus in the renal vein or inferior vena cava. Symptoms of this process are not clearly described in the literature.The aim of the study. On the basis of the study of the clinical course of RCC, which is complicated by implantation thrombosis of the renal vein and IVC, to determine the symptoms of the disease associated with the formation of obstruction of the IVC.Results. The overall condition of patients on the ECOG scale was as follows: 0 points were found in 83 (65.4%) patients, 1 in 39 (30.7%) and 2 in 5 (3.9%). Levels of distribution of tumorous thrombus by IVC were determined by the classification of the Meyo clinic: the zero level was 50 (39.4%) patients, I level – 26 (20.5%), ІІ level – 27 (21.2%), ІІІ level – 18 (14.2%) and IV level – 6 (4.7%). In 9 (7.1%) patients, in addition to tumorous thrombosis IVC, phlebotrombosis of the femur, iliac veins and IVC was diagnosed. In 32 (25.2%) patients, any symptoms were absent, and the detection of kidney tumors and tumorous venous thrombus was an accidental finding during an ultrasound examination or computer tomography for other diseases. Clinical symptoms were detected in 95 (74.8%) patients. The most common symptoms were the clinical manifesta-tions of local tumor spread in the form of pain in the lumbar region or abdomen (44.9%) and macrohematuria (33.9%). Symptoms of cancer intoxication as general weakness were found in 22.8% of cases. The symptoms of compression or ob-struction of the IVC in the form of right-sided varicocele were recorded in only one (0.8%) patient. Edema of the legs (in-crease in the volume of the legs more than 3 cm) was diagnosed in 9 (7.1%) patients, 6 of which were cyanosis of the legs. These were patients who, in addition to tumorous thrombosis, had a concomitant pathology in the form of phlebothrombosis of the femur, iliac veins and IVC. Conclusion. In 25.2% patients of RCC, complicated by implantation thrombosis of the renal vein and IVC has asympto-matic course and the detection of kidney tumors and tumor venous thrombus in them is a coincidence finding during an ultra-sound examination or computer tomography for other diseases. In this regard, patients with renal cancer should be obliged to perform ultrasound and X-ray examination of IVC for the purpose of detecting implantation thrombus. The presence of con-comitant phlebotrombosis of the of the femur, iliac veins and IVC should not be considered as a symptom, and complication of implantation thrombosis IVC.

Emergency conditions in vein disease are deep vein thrombosis or phlebothrombosis and superficial vein thrombosis or thrombophlebitis. They occur globaly in general population and are a significant cause of morbidity and mortality. Since deep vein thrombosis and pulmonary embolism very often come together, they are both reffered to as venous thromboembolism. Early recognition of deep or superficial vein thrombosis is extremely important and therapy with anticoagulants should immediately be innitiated in order to prevent potentially life-threatening thromboembolic complications. Thrombophlebitis is usually diagnosed through physical examination, but patients should be refered to dopler ultrasound of lower extremity veins to rule out the existence of deep vein thrombosis. Venous thromboembolism is initially diagnosed using a clinical scoring system to point out patients with high risk, and also the level of D-dimer in the blood. High risk patients with high probability of venous thromboembolism and high levels of D-dimer are then referred to further diagnostic procedures. Direct oral anticoagulants are the first line of treatment in venous thromboembolism therapy, since they carry a lower risk of haemorrhagic complications that vitamin K antagonists, as well as easier implementation without the need for monitoring. Anticoagulant therapy is used for at least three months in order to prevent early recidives, while patients with high risk of suffering from venous thromboembolism again should be taking prolonged anticoagulant therapy. Anticoagulant therapy, most commonly low-molecular heparin, together with the symptomatic therapy of non-steroid antiinflammatory drugs, is the base for treating thrombophlebitis.

OBJECTIVE. Based on our own experience and analysis of the literature, we want to demonstrate the features of diagnosis and treatment of ascending deep phlebothrombosis of the lower limbs and pelvis. MATERIAL AND METHODS. During the period from October 2008 to September 2016, in the First Clinic of Surgery (postgraduate medical education) of ”Military Medical Academy named after S. M. Kirov” we analyzed the results of treatment of 44 patients with this pathology. Selective surgical tactics was based on the evaluating of general status, activity of the patient, the presence of concomitant pathology, complications of the disease. Implantation of the cava-filter was performed in 23 patients. In active patients, without significant concomitant pathology, open thrombectomy operations were performed from the deep veins of the lower limbs or from the inferior vena cava and iliac veins (21 patients). In some of these patients, a removable cava-filter was implanted before thrombectomy (8 patients). Thrombectomy from the deep veins of the lower limbs was supplemented in 12 patients by the plication of the main vein. RESULTS. This tactic made it possible to achieve favorable results in the majority of patients (27 patients, 87 %) – there were no signs of recurrence of venous thromboembolic complications, there was complete or almost complete (more than 90 %) recanalization of thrombosed veins, venous insufficiency was limited by the presence of transient edema. Small hemorrhagic complications were noted in 2 patients. Relapses of venous thromboembolic complications occurred in a distant period in 3 patients. In order to prevent fatal pulmonary embolism, patients with ascending deep phlebothrombosis need surgical treatment. CONCLUSION. The choice of surgical treatment (cava filter implantation, deep vein thrombectomy) should be determined depending on the general status, patient activity, the presence of concomitant pathology, complications of the disease, and also individually in each specific clinical situation.

Cases of cranial superficial epigastric vein (CSEV) phlebitis with subsequent septicemia were observed in dairy farms in Minas Gerais, Brazil. Autopsy on 4 affected cows, from 2 farms, revealed CSEV thrombophlebitis with perivascular abscesses, pulmonary abscesses, valvular endocarditis, arthritis, thromboembolic nephritis, and renal infarcts. Microscopic examination revealed fibrosing and lymphoplasmacytic phlebitis with occasional endothelial loss, subendothelial areas of necrosis, and abundant fibrin deposition. Trueperella pyogenes, Escherichia coli, and Staphylococcus aureus were isolated from lesions of 3 different cows. Thrombophlebitis of the CSEV is a rare condition in dairy cows; however, it has become more frequent in dairy farms in southeastern Brazil after repeated venipuncture of this vein, likely with contaminated needles used for administration of oxytocin.

The analysis of long-term results of diagnosis and treatment in 1057 patients with embologenic phlebothrombosis in the inferior vena cava, including pregnant women (n=69) and postpartum women (n=33). Of particular interest is the study of genetic disorders of hemostasis that contribute to thrombosis in pregnant and postpartum women, thereby threatening the life of both mother and child. Observations of such patients within 5, 10, 15 or more years have confirmed a sufficient efficiency of that program of prevention and treatment of life-threatening situations developed by the authors, including the correction of genetic disorders of hemostasis, which led to the preservation of life and the safe delivery of all monitored patients in this group.

The purpose and objectives of this work was to study the character and severity of varicose veins of the legs on the background of arteriosclerosis and evaluation of medical measures in these patients. The study included 302 patients (227 men and 75 women aged 29-72 years), 16 % of which had previous phlebothrombosis and the frequency of II, III, IV, V and VI venous insufficiency class was 10 %, 14 %, 37 % 16 % and 23 %. 263 patients underwent endovenous laser coagulation, and 39 – the traditional phlebectomy and ligation of perforating vein. Arteriosclerosis of femur, tibia, iliac and popliteal arteries is observed in 23 % of patients with varicose veins of legs, more common in men and people who have had phlebotrombosis, which was accompanied by higher blood pressure and venous insufficiency parameters, more frequent involvement of the great saphenous vein in the process, larger diameter and its preestuarine extension, with that the results of endovascular ablation after two, four and twenty-four weeks were worse, in spite of the prevalence of using rivaroxaban and heparins in this group, and the frequency of complications of medical measures were 2,7 times higher, while complete occlusion of the vessel a month after the operation – in 3,2 times less, that was determined by the levels of thromboxane-A2, surface viscosity, elasticity and tension of venous blood serum, the last indicator had predictive value in the presence of arteriosclerosis, a surfactant index – in case of its absence.

The article presents a comparative analysis of the clinical course of pulmonary embolism and the effectiveness of thrombolytic therapy in patients with thrombophilia and in those without identified thrombolytic disorders. The impact of thrombophilia on the incidence of pulmonary embolism and phlebothrombosis was analyzed. The results obtained indicate the presence of thrombophilia in 25.7% of patients with pulmonary embolism. It was found out that thrombosis and embolism in the vena cava filter occurred more frequently in patients with thrombophilia rather than in those with pulmonary embolism of unknown etiology.

ZusammenfassungKatheterassoziierte Venenveränderungen weisen bezüglich ihres klinischen Bildes und ihres klinischen Verlaufs eine hohe Variabilität auf. Unterschieden werden kann zwischen einem perivenösen Hämatom, einer Periphlebitis, Endophlebitis, Phlebothrombose oder septischen Thrombophlebitis. Die Diagnosestellung einer Venenerkrankung erfolgt durch eine klinische Untersuchung (Anstaubarkeit der Vene, Schwellungen, Schmerzhaftigkeit, vermehrte Wärme und eventuelle Exsudation im Bereich der Einstichstelle) sowie eine sonographische Darstellung der Vene (perivenöses Gewebe, Venenwand, Veneninhalt). Die Behandlung der Venenerkrankung richtet sich nach ihrer Ätio logie und Pathogenese und kann aus einer antikoagulatorischen (Heparin, Phenprocoumon), einer entzündungs- und schmerzhemmenden (nichtsteroidale Antiphlogistika) sowie bei Bedarf einer antibiotischen Therapie bestehen. Zur Prophylaxe von Venenerkrankungen ist ein gutes Kathetermanagement besonders wichtig. Hierzu gehören die richtige Auswahl des Kathetersystems (Langzeitkatheter aus Polyurethan), die Katheterpflege und die intensive Überwachung. Der Übersichtsartikel erläutert praxisnah die einzelnen Venenerkrankungen, ihre Diagnose und die therapeutischen Maßnahmen.

Lymphedema is a chronic condition; therefore, in clinical practice, therapy is intended to return the disease to its latent phase (a condition relatively free from edema, despite the limited function of the lymphatic drainage system) and thereby to attain prolonged control of signs and symptoms of lymphedema. The objectives of physiotherapy include improvement of lymphatic vascular function, to soften fibrosclerotic irregularities, to reduce collagen deposition, and to reduce cutaneous microbial growth. The components of CDP are manual lymph drainage and compression therapy. The physiological effects of compression include displacement of fluid from the interstitium and reduction of venous pressure, reduction of lymphatic preload, increase in lymph formation, and increase in lymph flow through existing conduits, particularly during exercise. Complete decongestive therapy is a two-phase therapy. Contraindications to CDP include acute erysipelas, acute thrombophlebitis, phlebothrombosis, decompensated heart failure, and Stage IV peripheral artery occlusive disease. Patients with chronic lymphedema must be prepared for lifelong medical compression. Long-term results of conservative treatment of lymphedema with complete decongestive physiotherapy depend not only on the stage of lymphedema, during which treatment has begun, but also on the compliance of the patient, as well as the presence of comorbidities that aggravate edema as well on the skill of the therapist.

A 26-year-old unmarried male presented with voiding difficulty and penile oedema, was initially diagnosed and treated for Mondor’s disease, which is a rare, benign, usually self-limiting pathology of anonymous origin. When he failed to respond to conservative management, a biopsy from glans penis was taken which revealed it to be moderately differentiated Squamous Cell Carcinoma (SCC). Apart from being an old man’s affliction, usual presentations of penile cancer range from ulcerative lesion to exophytic growth. Thus, its presentation as thrombosis of dorsal vein of penis is astounding as depicted in this case.

Background: Venous disease is a common health problem in developed countries. The aim of this study was to research the medical treatment strategy, complication due to venous impairment including leg ulcer, deep and/or superficial phlebothrombosis related ...

Introduction: Several conditions represent the risk factor for deep vein thrombosis (DVT) but sometimes it occurs with no apparent reason. DVT usually involve lower extremities. It can be a component of paraneoplastic syndrome, and occasionally it is the first manifestation of malignancy. Case report: Fifty-five years old male reported to his general practitioner with history of painless right leg swelling of three weeks duration. He denied leg trauma or any other hardship. The patient had a long history of hypertension and took his medications irregularly. Family history was positive for cardiovascular diseases but negative for metabolic diseases or malignancies. He was a smoker and physically active. Physical examination revealed right calf swelling without skin discoloration, distention of superficial veins or trophic changes. Pulses of magistral arteries of the leg were symmetrical, Homans' sign was positive on the right leg. The rest of the physical examination was normal, except for the blood pressure. He was referred to vascular surgeon with the clinical diagnosis of femoro- popliteal phlebothrombosis of the right leg. Vascular surgeon performed the Color duplex scan of the lower extremities which confirmed the diagnosis. The patient was treated with low-molecular-weight heparin. The swelling significantly subsided after two weeks of therapy, but then patient fell and fractured left ramus of ischial bone. X-ray examination of pelvis revealed both fracture line and osteoblastic deposits in pelvis and the fracture was pronounced pathological. In order to localize the primary tumor, subsequent tests included chest X-ray, abdominal and pelvic ultrasound and digitorectal examination of prostate were performed. The results of all of the above mentioned examinations were within normal ranges, including routine blood tests. Skeletal scintigraphy revealed multiple secondary deposits in pelvic bones, vertebral column and ribs. Tumor markers' values were within normal ranges, except the level of prostate specific antigen which was 2250. The patient was diagnosed with prostate cancer and referred to urologist who recommended surgical treatment. The bilateral orchiectomy with transrectal ultrasound- guided biopsy of prostate was performed. Pathological analysis confirmed the diagnosis of prostatic adenocarcinoma. Conclusion: Detailed evaluation of patients with DVT without predisposing conditions is compulsory in order to minimize the chance of misdiagnosing some severe conditions.

Fibrinolytic therapy for DVT has not gained universal acceptance. A notable percentage of DVTs in Germany are treated by clot-dissolving methods. This is in contrast to clinical practice in the United States where fibrinolytic treatment for DVT is virtually unknown. It is unique in modern medicine that such a frequent disease is treated so differently on a national basis. The PHLEFI Study is a multicenter, prospective trial on the fate of 1498 patients receiving different forms of fibrinolytic therapy for DVT (ultrahigh streptokinase and urokinase short-term therapy, streptokinase, urokinase, and rt-PA long-term infusions, locoregional and sequential therapies). Interest focused primarily on side-effects such as cerebral bleeding and fatal pulmonary embolism as well as on the clinical outcome in terms of revascularization. The major factor for the rate of cerebral bleeding under fibrinolytic therapy was the age of the patient (0.355% bleeding in patients under and 2.03% in patients over 50 years). The major factor for pulmonary embolism was the site of the thrombosis (2.16% with iliac, 0.701% with femoral, none with popliteal, calf and subclavian vein thromboses). Use of a temporary caval filter during lysis therapy eliminated fatal pulmonary embolism. Results of lytic therapy were stated as complete, partial, and no clearance. The outcome was dependent on the thrombus age and the medication used. The highest clearance rate achieved was 50% in patients treated with short-term ultrahigh streptokinase therapy and a history of up to three days. Fibrinolytic therapy for DVT is a reliable means of achieving revascularization. The above data may enable the physician to balance the usefulness of this therapeutic method against the risk of its side effects.

Background/Aim. Deep venous thrombosis (DVT) is a lifethreatening condition, which could be manifested with discrete symptoms (silent DVT). High mortality and disability of patients with DVT indicate the importance of early diagnosis, especially of 'silent' DVT. The aim of this paper was to evaluate of reliability of early detection model for diagnosing DVT in ambulatory patients by using clinical probability of DVT presence, D-dimmer test (DD) and ultrasound evaluation (US). Methods. Ambulatory patients with suspected DVT were classified as 'unlikely' and 'likely' DVT by the Wells clinical model. The patients were randomly divided into the control and DD group. In the control group (629 patients) only US examination of lower limbs deep vein was done. All patients in the DD group (643 patients), with 'unlikely' TDV, had DD, and in the positive patients US examination was done. In the 'likely' patients US examination was done and negative US finding indicated DD test. Positive DD test was an indication for US examination after 7 days. The patients with initially excluded DVT were evaluated during 3 months. Results. A total number of 1 272 patients were examined; 117 (9.19%) patients were with DVT - 62 (9.64%) in the DD and 55 (8.74%) in the control group. During the follow-up periods in the DD group (with 582 initially excluded DVT) we registered DVT in only one patient (0.17%). It was significantly lower (p < 0.05) compared to the control group where we registered 7 (1.1%) DVT (a group with 581 initially excluded DVT). The applied DD diagnostic strategy for 70.7% (p < 0.001) reduced the need for US examination. Conclusion. The applied DD strategy in the diagnostic of DVT reduces the need for US examinations and reduces frequency of false negative results, with direct impact on cost and efficacy of procedures. DD diagnostic model should replace serial US examination in patients with suspect DVT.

In the last six years the authors have implanted 340 hip joint prostheses of the Zweymuller/Endler or Zweymuller type in 285 patients from the lateral transgluteal approach. Approximately one-third of these patients (111) had previously undergone surgery on the hip joint in question. Intraoperative complications included four cases of elongation of the leg due to implantation of an over-long prosthesis shaft. Four of the shafts implanted were too small and in two cases subsequently loosened. In two patients a divulsion of the trochanter major occurred and there were two cases of cracking of the calcar femoris with involvement of the trochanter minor. There were also two cases of shaft divulsion at the level of the prosthesis tip. Postoperative complications included periarticular ossifications in 41 cases. There were 11 cases of phlebothrombosis and six of pneumonia. Superficial hematomas developed in the wound region in four cases. In addition, there were two cases of shaft and one of acetabular loosening, as well as three prosthesis dislocations. Between October and December 1987, a total of 232 of these patients were examined and the results rated according to Merl d'Aubigne's classification: 166 (71%) were classified as very good or good, 49 (21%) as satisfactory, and 17 (7%) as unsatisfactory. The most common postoperative complication was periarticular ossification, seen in 41 cases. Even though this is not a serious complication and the periarticular ossifications did not necessarily result in severe limitation of movement, a major functional loss as compared to the preoperative findings was seen in the patients with severe ossification (IIIrd degree) at the examination 12 months postoperatively. By giving EHDP, since November 1984, it has proved possible to reduce the incidence of periarticular ossifications from 28 to 12%. In the last 24 months even better results have been achieved by administration of EHDP unter function-scintigraphic control. According to the author's results the Zweymuller/Endler and Zweymuller systems satisfy the requirements for a cement-free total hip replacement since, on the one hand, intraoperative and postoperative complications are slight and, on the other, a good functional result is achieved. The Zweymuller prosthesis has proved particularly suitable for hip joints operated on previously.

In a prospective study the reliability of colour-coded duplex-sonography (CCDS) and phlebography in the diagnosis of deep leg and pelvic vein thrombosis was compared. In 82 consecutive in- or out-patients (42 men, 40 women; mean age 53 [19-86] years) with clinically suspected leg or pelvic vein thrombosis the results of 275 phlebographies (reference method) and 275 CCDS were compared on admission and during follow-up. The two methods were performed less than 6 hours apart. In the diagnosis of thrombosis the sensitivity of CCDS was 99%, specificity 80%. In 88% of all tests, the different thrombosis levels, as diagnosed by phlebography, were also demonstrated by CCDS. These data indicate that, if the clinical picture of suspected deep leg or pelvic vein thrombosis is unclear, CCDS should be done first. Phlebography should be performed only if the results of the former are inconclusive.

HISTORY AND ADMISSION FINDINGS Severe pain and increasing swelling in the region of the right lower leg occurred after unaccustomed physical activity in a 29-year-old man. Physical examination showed painful swelling and livid discoloration of the right lower leg. INVESTIGATIONS Laboratory tests were consistent with an acute inflammation. Colour Doppler duplex sonography of the leg and pelvic veins bilaterally revealed complete thrombosis of the deep leg and pelvic veins on the right. Spiral computed tomography of the abdomen confirmed deep pelvic vein thrombosis and also demonstrated complete agenesis of the inferior vena cava (IVC). TREATMENT AND COURSE The patient was fully heparinized and compression bandage applied to the right leg, which was kept elevated, Ibuprofen, 3 x 400 mg daily, was given for pain relief. Anticoagulation treatment with phenprocoumon (Marcumar) was initiated. The patient was discharged much improved after ten days. Duplex sonography after 3 months demonstrated partial recanalization of the right pelvic and deep leg veins. CONCLUSION Congenital malformations of the IVC are rare. Phlebothrombosis often results in affected patients. Treatment or prevention of thrombosis of the deep veins by anticoagulation is indicated. Additional risk factors for thrombosis--smoking, hormonal contraceptives, immobilization and unusual physical activity--should be strictly avoided.

Between November 1988 and February 1990, a total of 180 patients (76 men and 104 women; mean age 59 [17-79] years), suspected of having sustained a deep-vein or pelvic thrombosis were examined by colour Doppler ultrasound, the results being compared with those obtained by conventional phlebography. For 154 phlebographically confirmed acute venous thromboses (demonstrated by colour Doppler ultrasound in 153), four older thromboses (colour Doppler ultrasound: 7), and 22 without significant venous disease (colour Doppler ultrasound: 20), the specificity for colour Doppler ultrasound was 99%, its sensitivity 94%. In 49 patients with confirmed venous thrombosis thrombolytic treatment was started with 250,000 IU urokinase, followed by 62,500 IU hourly, the results being assessed by colour Doppler ultrasound and phlebography. This gave a specificity, compared with phlebography, of 99%, and a sensitivity of 97%. These data indicate that, in the diagnosis of venous thrombosis of the legs, colour Doppler ultrasound noninvasively provides information at least as reliable as phlebography. It may even be superior to phlebography in the demonstration of residual flow in partly thrombosed veins.

A 26-year-old woman, on bedrest since the 6th week of pregnancy because of threatened abortion, developed thrombosis in the left iliac, superficial femoral and common femoral veins with small pulmonary emboli in the 11th week. Inhibitor deficiency was excluded. The thrombosis was only partially recanalized by unfractionated heparin at therapeutic dosage (38,400 IU per 24 h). As thrombolysis treatment and oral anticoagulation were contraindicated because of the threatened abortion, coagulation with low molecular weight heparin (LMWH) was started in the 18th week (5000 anti-Xa units daily subcutaneously). Maximal anti-Xa activity in plasma never exceeded 0.3 U/ml and there were no complications. The patient was delivered of a healthy girl (2,660 g, 48 cm) by caesarean section in the 37th week. Immediately post-partum LMWH was demonstrated with an anti-Xa activity of 0.3 U/ml in maternal blood, but none in simultaneously obtained cord venous blood. This case suggests that treatment of phlebothrombosis with LMWH is a reasonable measure even during pregnancy.

In a prospective study we compared colour duplex ultrasound to venography in 325 patients with clinically suspected acute lower extremity deep vein thrombosis. In 269 cases of proven thrombosis overall sensitivity and specificity of colour duplex ultrasound were 98% and in calf vein thrombosis 96%. Investigations by both methods after fibrinolytic urokinase therapy of phlebothrombosis in 53 patients revealed no significant diagnostic differences between the two methods. In 115 patients with clinically suspected chronic venous insufficiency colour duplex ultrasound allowed to differentiate between occluded, partially recanalised or normal deep veins with or without venous valve incompetence and superficial venous insufficiency. In this study colour duplex ultrasound in diagnosis of acute or chronic lower limb venous disease attained results that were comparable to those obtained by phlebography.

Two children with clinically suspected renal vein thrombosis were evaluated by duplex Doppler sonography and colour flow imaging. Both cases presented unspecific findings with an enlarged kidney and loss of cortico-medullary delineation on gray-scale ultrasound, but an unusual flow pattern with retrograde plateau-like frequency shifts during diastole. No venous signal could be obtained. By colour flow imaging only the main renal artery and its proximal branches could be visualised with a reverberating oscillation of blood flow. In addition, partial thrombosis of inferior vena cava in one patient and iliac vein thrombosis in the other could be demonstrated. Clinical improvement during fibrinolytic therapy in one case and nephrectomy in the other case confirmed the diagnosis.

Essentials The association of superficial vein thrombosis (SVT) with venous thromboembolism (VTE) is variable. We performed a meta-analysis to assess the prevalence of concomitant VTE in patients with SVT. Deep vein thrombosis was found in 18.1%, and pulmonary embolism in 6.9%, of SVT patients. Screening for VTE may be worthy in some SVT patients to plan adequate anticoagulant treatment. Summary Background Some studies have suggested that patients with superficial vein thrombosis (SVT) have a non-negligible risk of concomitant deep vein thrombosis (DVT) or pulmonary embolism (PE) at the time of SVT diagnosis. Unfortunately, the available data on this association are widely variable. Objectives To perform a systematic review and meta-analysis of the literature in order to evaluate the prevalence of concomitant DVT/PE in patients with SVT of the lower limbs. Methods Studies reporting on the presence of DVT/PE in SVT patients were systematically searched for in the PubMed, Web of Science, Scopus and EMBASE databases. The weighted mean prevalence (WMP) of DVT and PE was calculated by use of the random effect model. Results Twenty-one studies (4358 patients) evaluated the prevalence of DVT and 11 studies (2484 patients) evaluated the prevalence of PE in patients with SVT. The WMP of DVT at SVT diagnosis was 18.1% (95%CI: 13.9%, 23.3%) and the WMP of PE was 6.9% (95%CI: 3.9%, 11.8%). Heterogeneity among the studies was substantial. Selection of studies including outpatients only gave similar results (WMP of DVT, 18.2%, 95% CI 12.2–26.3%; and WMP of PE, 8.2%, 95% CI 3.3–18.9%). Younger age, female gender, recent trauma and pregnancy were inversely associated with the presence of DVT/PE in SVT patients. Conclusions The results of our large meta-analysis suggest that the prevalence of DVT and PE in patients presenting with SVT is not negligible. Screening for a major thromboembolic event may be worthwhile in some SVT patients, in order to allow adequate anticoagulant treatment to be planned. Other high-quality studies are warranted to confirm our findings.

Dear Editor, A 44 year-old female patient was admitted via the emergency room with an acute-onset left-sided frontal-temporal headache. The patient's medical history of migraines and superficial venous thrombosis was significant, but she did not take any regular medications. No history of smoking, excessive alcohol consumption, or drug use was reported, nor any family history of stroke/myocardial infarction or angiopathy. The patient did not complain of other symptoms. A neurological examination revealed no focal deficits or other findings. There were no pathological findings in a brain CT scan performed at admission. However, a MRI scan performed 24 hours later produced findings consistent with acute infarction of the temporal branch of the left middle cerebral artery (Supplementary Fig. 1 in the online-only Data Supplement). The patient was put on dual antiplatelet therapy (aspirin and clopidogrel), in accordance with current American Heart Association/American Stroke Association guidelines, pending further diagnostic workup. Blood screening did not identify any vascular risk factors, including hypercholesterolemia, diabetes mellitus, coagulation disorders, or autoimmune diseases. The results of a cardiologic evaluation, including transthoracic echocardiography and 24-hour Holter monitoring, were normal. CT angiography revealed no stenoses in either extracranial or intracranial vessels. Transesophageal echocardiography (TEE) revealed the presence of a patent foramen ovale (PFO) with a large right-to-left shunt during the Valsalva maneuver (Fig. 1), and so the antiplatelet treatment was switched to oral anticoagulation with acenocoumarol due to the history of superficial venous thrombosis.1 The patient remained asymptomatic during the hospital stay and was discharged with no deficit. At the 3-month after stroke onset re-evaluation the patient remained asymptomatic with no cerebrovascular incident recurrence. Fig. 1 Patent foramen ovale with a large right-to-left shunt during the Valsalva maneuver (>20 microbubbles) identified using transesophageal echocardiography. There is increasing skepticism about the diagnostic utility of TEE in patients with cryptogenic cerebral ischemia, due to both the high intrarater variability for the method and the low prevalence of identified cardiac conditions that are finally considered to be causally associated with the ischemic event.2 This controversy led to the currently proposed criteria for the definition of embolic strokes of undetermined source (ESUS), which do not include TEE in the mandatory diagnostic workup for an ESUS diagnosis.3 In the present case report, all of the results obtained in the routine diagnostic stroke workup were normal, whereas TEE finally not only uncovered the missing link between superficial venous thrombosis, migraine,4 and cerebral ischemia and the possible underlying pathophysiological mechanism, but also had a crucial impact on secondary prophylaxis and prognosis.5 Because of the patient's young age, the absence of conventional vascular risk factors, the presence of a superficially located lesion (risk of paradoxical embolism score=8/10), and the history of lower limb phlebothrombosis, the discovered PFO was considered to be stroke-related rather than incidental.6 This case report suggests that patients with cerebral ischemia in the absence of conventional risk factors should undergo investigation with TEE to search for potential cardiogenic or aortogenic embolic sources. It also demonstrates that examining single cases can lead to important observations with significant clinical applications.7 Not all of the important clinical answers can be answered by large-scale analyses of possibly heterogeneous patients. In cases of ESUS, we should continue the thorough search of the locations, from which embolic material arrise.8

A case is presented of a 39-year-old primigravida who developed iliofemoral-popliteal thrombosis in the 34th week of twin pregnancy. Thrombectomy by use of a Fogarty catheter with previous protection from thrombus embolization by proximal placement of temporary occlusion was performed at the same time as the cesarean section for completion of premature delivery.

Deep vein thrombosis (DVT) and pulmonary embolism are major causes of morbidity and mortality in patients during hospitalization; previous studies have proposed that an advanced age of more than 60 years is a risk factor for these conditions. This study analyzes the relative risk of DVT in very elderly patients older than 90 years of age compared with elderly patients aged 80 to 89 years. The study was performed at the Department of Internal Medicine, University Hospital of Saarland, Homburg/Saar, Germany, between 2004 and 2012. After completing ultrasound examinations, 20 (64.52%, 12 [60%] female patients, mean age 91.8 ± 1.83 years) of the 31 patients in the study group and 132 (62.26%, 87 [65.91%] female patients, mean age 83.84 ± 2.66 years) of the 212 patients in the control group were diagnosed with DVT. An increased relative risk of DVT was not discovered in the very elderly patients (relative risk, 1.04; P = .80).

HISTORY AND CLINICAL FINDINGS A 37-year-old German fell ill with fever and diffuse headaches 3 weeks after flying to Thailand for a holiday. Because of increasing sickness he began his return (13 h by train then 11 h by plane). Besides a temperature of 39.3 degrees C he presented with a unproductive cough and pain in his left calf. On examination there were no other pathological findings than a borderline tachycardia, mild hypotension and signs of dehydration. INVESTIGATIONS Laboratory tests showed elevated inflammatory parameters (CRP 77.8 mg/l, ESR 36 mm), normal range of leucocytes with obvious shift to the left, mild thrombocytopenia and elevated liver enzymes. The Weil-Felix-reaction revealed a high antibody titre against OX 19, the IFT for Rickettsia typhi a significant increase of IgM with seroconversion for IgG. Duplex ultrasonography and phlebography confirmed a phlebothrombosis of the left upper thigh. DIAGNOSIS Murine typhus and deep vein thrombosis of the left upper leg. TREATMENT AND COURSE Suspecting typhoid fever with ciprofloxacin was started. In less then 2 days the patient became afebrile and recovered. The deep vein thrombosis was treated with low-molecular-weight heparin (Tinzaparin) overlapping with phenprocoumon. CONCLUSION In patients with fever after travel to tropical or subtropical areas (including southern Europe) the diagnosis of murine typhus should be considered, especially if concomitant with thromboembolic events. The Weil-Felix-reaction is a helpful screening test supplemented by Rickettsia specific serologic tests. Overall a higher risk of thrombosis should be taken into account after long sedentary travel.

The purpose of this retrospective study was to analyse the complications of our arthroscopic procedures at the ankle joint. In all patients we evaluated the treatment protocols and in 111 patients (79.3%) we also evaluated the clinical and radiologic results. All in all we have found complications in 14 patients. In 4 cases we have seen a delayed wound healing, in 2 cases a superficial infection, in 3 cases a deep infection, in 3 cases a neural damage and in 2 cases a phlebothrombosis. Our study show, that the complication rate could be minimized by detailed knowledge of the anatomy, exact preoperative diagnostic and planing of the operation and careful preparation of the portals. The use of a laser also shows a tendency to a lower complication rate.

The objective of this study was to evaluate the incidence of infrapopliteal deep vein thrombus propagation in postoperative orthopedic patients. This was a retrospective study of patients undergoing noninvasive venous testing to rule out phlebothrombosis. Venous duplex scans and Doppler studies to record thrombus location were performed at the end of treatment, which lasted from 2 weeks to 1 year (mean: 6 months). The study included 28 postoperative orthopedic patients; 21 men and seven women with a mean age of 52 years (range: 14 to 92 years). Patients received three different treatment regimens. Group I received heparin and warfarin (n = 17; 60.7%); Group II received warfarin (n = seven; 25%); Group III received aspirin (n = four; 14.3%). Isolated tibial vein thrombosis was found in 10 patients, (36%) and 18 patients (64%) exhibited multiple tibial veins involvement. Follow-up venous duplex and Doppler studies revealed a single episode (5.9%) of thrombus propagation from an isolated tibial vein to multiple tibial veins in Group I. There were four Group II patients with isolated and three with multiple tibial vein thrombi. Clot propagation occurred in three (42.9%) instances; two originated from isolated tibial vein thromboses and all extended into the popliteal and femoral veins. No propagation occurred in the limbs of Group III. Statistical analysis of treatment protocols revealed a significant difference in outcome (clot propagation) based on management. Warfarin therapy alone (Group II) resulted in a significantly increased risk for clot propagation (p < 0.04), whereas there was no difference in the incidence of clot propagation based on the number of involved tibial veins (p < 0.12). Warfarin treatment alone was not found to be an effective method of preventing thrombus propagation in postoperative orthopedic patients with tibial vein thrombosis. The treatments using heparin/warfarin or aspirin alone were found to be equally effective for preventing this complication.

A case of rupture of an aneurysm of the pancreaticoduodenal artery which occurred 2 years and 4 months after operation for a rectal cancer was successfully managed by transcatheter arterial embolization therapy. A 62-year-old man who had no previous history of pancreatitis nor arteriosclerosis had an uneventful course after an operation for a rectal cancer. With a diagnosis of phlebothrombosis of the left lower limb, oral administration warfarin pottasium 3.0mg/day was started when it passed one year and 9months after the operation, and at the same time increases in CEA and CA19-9 were noted. Recurrence was suspected and oral administration of doxifluridine 1200mg/day was also started. Thereafter no particular problems arose, however, the patient was seen at the hospital in shock state because of abrupt massive anal bleeding. Emergency angiography offered a diagnosis of gastrointestinal bleeding due to rupture of an aneurysm of the inferior pancreaticodudenal artery. So an embolization via metal coil was conducted. The patient was able to relived from the shock state and anal bleeding disappeared thereafter. However, the patient died of local recurrence as of 6months after the embolization or 2years and 9months after the operation for the rectal cancer.

The objective of this prospective study was to evaluate the accuracy of color Doppler imaging in comparison to phlebography in diagnosing phlebothrombosis. Five hundred and twenty-six phlebographies (reference method) were compared with 526 color Doppler sonographic examinations. Thrombosis diagnosed with color Doppler imaging showed a sensitivity of 98.0% (400 of 408). In 91.6% (482 of 526) of all examinations the extent of the thrombosis diagnosed with phlebography could also be seen with color Doppler imaging. When the clinical situation is unclear, color Doppler imaging should precede phlebography. Only when findings with ultrasonography are questionable should phlebography definitely be considered.

Reduction in maternal mortality requires an in-depth knowledge of the causes of death. This study was conducted to explore the circumstances and events leading to maternal mortality through a holistic approach. Using narrative text analysis, all documents related to maternal deaths occurred from 2007 to 2011 in Kerman province/Iran were reviewed thoroughly by an expert panel. A 93-item chart abstraction instrument was developed according to the expert panel and literature. The instrument consisted of demographic and pregnancy related variables, underlying and contributing causes of death, and type of delays regarding public health aspects, medical and system performance issues. A total of 64 maternal deaths were examined. One third of deaths occurred in women less than 18 or higher than 35 years. Nearly 95% of them lived in a low or mid socioeconomic status. In half of the cases, inappropriate or nonuse of contraceptives was seen. Delay in the provision of any adequate treatment after arrival at the health facility was seen in 59% of cases. The most common medical causes of death were preeclampsia/eclampsia (15.6%), postpartum hemorrhage (12.5%) and deep phlebothrombosis (10.9%), respectively. Negligence was accounted for 95% of maternal deaths. To overcome the root causes of maternal death, more emphasis should be devoted to system failures and patient safety rather than the underlying causes of death and medical issues solely.

Hemorrhoidal disease is a very common and widespread disease, and it is estimated that about one subject out of three may suffer from this pathology. Hemorrhoids generally cause symptoms when enlarged, inflamed, thrombosed, or prolapsed. Internal hemorrhoids arise above the dentate line (in comparison to external hemorrhoids - perianal phlebothrombosis) and are covered by transitional or columnar epithelium. Scleotherapy is one of the oldest therapy forms mainly for bleeding hemorrhoids. The so called Barron ligature is an office procedure in which a small rubber band is placed at the base of the internal hemorrhoid with a special applicator.

BACKGROUND. The coup de fouet syndrome is an uncommon condition characterized by a spontaneous intramuscular venous hemorrhage of the calf, sometimes accompanied by a deep thrombosis of the leg. OBJECTIVE. The purpose of this work is to verify the real incidence of the thrombotic complications, making use of the most recent noninvasive diagnostic instruments, such as the duplex scanner and color Doppler. METHODS. From January 1992 to December 1993, we examined 24 subjects (average age, 38.5 years) suffering from the so-called coup de fouet syndrome, which had appeared during physical activity : walking (nine cases), running (six cases), and sudden changes of position (nine cases). In all cases we performed a clinical and instrumental examination (analogical and tensive arterial and venous Doppler, arterial and venous duplex scanner, and color Doppler). RESULTS. Clinically we found, in 17 subjects, a hematoma in the posterior calf with increased thickness and, in 10 cases, with spontaneous sharp pain. In the other seven cases we found a modest hematoma without subjective or other objective symptoms. The arterial Doppler and scanner findings were normal. In the first group of 17 cases, the average clinostatic Doppler venous pressure, measured using a method developed by us and already described, was 32 ± 4 mm Hg (normal value, 15 ± 7 mm Hg) ; in the other seven cases the value was 19 ± 4 mm Hg. CONCLUSION. The duplex scanner and color Doppler examination confirmed in all subjects the presence of an intrafascial hematoma in the gemellar zone ; in 10 cases (41.7%), with more painful symptomatology, in a zone contiguous to the hemorrhage, we found a gemellar (six cases) or popliteal (four cases) phlebothrombosis. Lastly, we must point out that the syndrome is not always benign and that, therefore, a correct and more vigilant diagnostic and therapeutic approach is necessary.

Epicardial fat (EpiF) reflects abdominal visceral adiposity and visceral fat plays an important role in the development of an unfavorable metabolic and atherosclerosis risk profile. An increased cardiovascular risk has been evidenced in patients with deep venous thrombosis (DVT). Advancing age is characterized by alterations of body fat mass and function In this study we studied the association between EpiF, DVT, age, obesity and other atherosclerosis risk factors.77 patients were recruited: 44 men and 33 women, 38 without DVT (65.9 ± 16.3 years, range 26-92 years) and 39 with DVT (65.4 ± 17.2 years, range 28-90 years). The study design was balanced for established atherosclerosis risk factors (gender, obesity, smoking habits, dyslipidemia, diabetes mellitus, arterial hypertension), for previous cardiovascular events, for use of statins and platelet anti-aggregating agents. Multivariate regression model and RECPAM regression tree were used to study the association between EpiF thickness and the other potential risk factors. Patients with DVT showed a thicker EpiF with respect to those without DVT (12 ± 2 mm vs. 9 ± 2 mm respectively, p 0.001). Multivariate linear regression model showed that DVT, obesity and age were positively associated with EpiF thickness after adjusting for the established atherosclerosis risk factors. Furthermore, the RECPAM analysis was performed to evaluate interactions between DVT, age and obesity: four main distinct and homogeneous subgroups of patients in terms of EpiF thickness were identified. The most important variable in partitioning patients was represented, as expected, by DVT (p 0.001) followed by age (p = 0.004), while obesity did not contribute to the model as well as the other atherosclerosis risk factors. Patients with DVT and older than 41 years of age had higher EpiF thickness in respect of patients with DVT and younger than 41 years of age. In patients without DVT the estimated cut-off age was 50 years, and older patients had thicker EpiF in respect of patients younger than 50 years of age.DVT should be considered as strongly associated with EpiF thickness. Advancing age (with or without spontaneous DVT) is significantly associated with an increased EpiF thickness. The measurement of EpiF thickness, a valuable marker of cardio-metabolic risk, may represent a useful and reliable method to evaluate cardiovascular risk in patients with idiopathic deep phlebothrombosis.

✓ Lumbar epidural varices have been infrequently described in the literature and rarely accepted as a primary pathophysiological entity. The authors' total experience with symptomatic lumbar epidural varices over the last 15 years includes four cases (incidence 0.067% of all lumbar spine operations), two of which are described in detail in this paper. The mechanism for their formation is proposed: central disc herniations obstruct the anterior epidural venous flow leading to anterolateral caudal venous distention. Subsequent venous endothelial injury predisposes to varying degrees of phlebothrombosis. Decompression of partially thrombosed varices may occur during operative discectomy or spontaneously during regression of the nonoperated disc prolapse. Regression of the central disc herniation may also explain the “disappearing disc” phenomenon, in which patients with clinical and radiographic evidence of apparently large caudal disc herniations exhibit clinical and radiographic resolution. Magnetic resonance (MR) imaging characteristics of the epidural varix depend upon the degree of thrombosis within this anomaly. A thrombosed varix is hyperintense on T1-weighted, proton-density, and T2-weighted images, whereas flowing blood is hypointense. The variable hypo- and hyperintensity on the T2-weighted MR imaging sequences correlate with a partially patent lumen within the varix.

Purpose: The purpose of this study was to use color-flow duplex scanning to identify the anatomic distribution of venous reflux and to quantify venous reflux times in patients with various stages of chronic venous insufficiency (CVI). Methods: Color-flow-assisted duplex scanning was used to identify the anatomic distribution of venous reflux and to quantify reflux times in the deep and superficial venous systems of patients with symptomatic (CVI). Two hundred two patients with class I to III CVI were examined. Results: Only 11% (22 patients) had a documented history of phlebothrombosis. Of the 403 limbs evaluated, 192 had venous ulcers whereas 211 were classified as having class I or II CVI. Nonocclusive venous obstruction was found in only 16 limbs (4%). Venous ulceration was significantly associated with reflux in multiple venous segments as opposed to reflux in isolated venous segments ( p t ) was determined by summing the reflux times of all the venous segments in a limb. The mean R t of patients with venous ulcerations was significantly longer than the mean R t of limbs with class I and II CVI ( p p p

For the past three and a half years postoperative venous thrombosis has been treated at the Lahey Clinic largely by anticoagulation therapy. For the last two and a half years femoral section and ligation have been reserved for cases of ambulatory recurrent calf phlebothrombosis with one or more benign pulmonary emboli or postoperative cases in which a second stage operation must be carried out. So far there have been one death from pulmonary embolism and four recurrent benign pulmonary emboli in 125 cases so treated. This death occurred early in the series after anticoagulation therapyhad been needlessly abandoned to treat anemia with a transfusion. Three of the four recurrent benign pulmonary emboli recurred when the prothrombin time was not adequately reduced owing to insufficient dosage of Dicumarol (3,3'-methylene-bis-[4-hydroxycoumarin] ). In 2 of these cases Dicumarol therapy was continued, with subsequent adequate control of the prothrombin time and no further incident.

NOTHING so captivates the medical mind as the prevention of catastrophe by a simple method. Thus may be explained the rapidly increasing popularity of proximal ligation of thrombosed veins for the prevention of pulmonary embolism. Indeed, there must be few surgeons, who have not witnessed the shockingly sudden transition of a happy convalescent into a patient rapidly dying from this totally unexpected disaster. Nor is the picture of so-called "thromboembolism"1 infrequent. Neumann2 in a study of 165 random cadavers, found that 65 per cent of them demonstrated ante-mortem venous thromboses of the lower leg, 52 per cent of which were . . .

Background: Ultrasonography has been widely applied in clinical settings, and its role in the assessment of trauma has been approved. However, there are very few reports about its role in the management of mass casualties. Methods: In our hospital, we retrospectively analyzed the application, the methods, and the role of ultrasonography in rescuing the Wenchuan earthquake victims. Results: On a total of 3,307 wounded patients, 1,207 were examined by ultrasonography, and on a part of them, a follow-up was also performed. A total number of 1,386 ultrasound examinations were performed. Among them, 115 patients received ultrasound-guided interventional diagnosis and treatments. Ultrasound screening detected 23 cases of hemoperitoneum, 45 cases of pleural effusion (blood), 1 case of traumatic intimal tear of femoral artery, 3 cases of deep veins phlebothrombosis of lower limbs, 12 cases of deep-part hematoma of soft tissues. In five cases of negative results by ultrasonography, visceral injury was confirmed later by surgery or computed tomography or contrast-enhanced ultrasonography. All the ultrasound-guided interventional treatments were performed successfully, without any serious complication. The detection rate of trauma-related diseases was 6.96% (84 of 1,207) without false positive; however, the false negative rate was 5.6% (5 of 89). The bedside ultrasound became the preferred examination for the majority of injuries in middle and later stage after earthquake (72 hours to 6 weeks), accounting for 73.9% (458 of 620) of examinations. Ultrasonography-based FAST method was the primary examination tool of trauma in the early stage after earthquake. Conclusion: In our hospital, ultrasonography was widely used in the triage of earthquake victims, bedside examination of severe cases, and interventional treatments. The advantages of ultrasonography such as convenience, noninvasiveness, high accuracy, and repeatability have been sufficiently demonstrated in this mass casualty, where ultrasonography played a great role in the rescue of victims of Wenchuan earthquake.