1/137. leg ulcers: a common problem with sometimes uncommon etiologies. In the U.S., leg ulcers present a significant clinical problem, occurring at a rate of approximately 600,000 new cases per year. In most cases, the cause of ulceration is venous or arterial in nature. One uncommon but significant cause of leg ulcers is sqaumous cell carcinoma (SCC). Although the incidence of SCC is higher in white than black populations, blacks with SCC typically exhibit involvement of areas of the skin that are not chronically sun-exposed, especially the lower extremeties. Predisposing factors include burn scars, chronic infection or ulceration, and chronic discoid lupus erythematosus. leg ulcers of atypical presentation or those that fail to heal should alert the clinician to consider uncommon etiologies. ( info) |
2/137. Bypass graft of an occluded inferior vena cava: report of a case with patency at five years. Venous reconstructive surgery for chronic occlusive disease has evolved slower than its arterial counterpart. Factors intrinsic to the venous system that have been implicated in discouraging experimental and clinical results include enhanced graft thrombogenicity, low velocity of blood flow, and wall collapsibility. 1,2 We present a case of a 24-year-old man with symptomatic occlusion of the inferior vena cava, treated with a prosthetic bypass graft to the supra diaphragmatic cava. The graft was patent 5 years later, and the patient remained asymptomatic. ( info) |
3/137. Temporary arterio-venous shunts to dilate saphenous crossover graft and maintain graft patency. A modification of the Palma operation is described in a 25-year-old man with impaired venous outflow of the right leg. After a phlebitic occlusion of the right superficial femoral and external iliac veins he had been operated on twice for varicose veins. The result of these operations was a serious outflow stasis of the right leg during exercise. A saphenous cross-over graft to the right popliteal vein was constructed. Preoperatively a temporary arterio-venous shunt between the left posterior tibial artery and the great saphenous vein had been made in order to increase the diameter of the saphenous vein. Three months later the dilated saphenous vein was resected at the level of the sapheno-tibial artery shunt and anastomosed to the popliteal vein of the right leg. The cross-over graft occluded several times during this operation. A temporary popliteo-popliteal arterio-venous shunt was established distally to the sapheno-popliteal anastomosis to keep the vein graft patent. This second arterio-venous shunt was resected after three months. Venography one month later showed that the vein graft was patent. The patient's complaints had disappeared one month after the operation and a normalization of his venous outflow was recorded plethysmographically. The graft has remained patent during an observation time of eighteen months. ( info) |
4/137. Local subcutaneous heparin as treatment for venous insufficiency in replanted digits. In the treatment of venous insufficiency unsuitable for surgical correction in replanted digits, a small ungual window was surgically created to infiltrate subcutaneous heparin in the congested digit. The initial heparin dose was 1000 units. This dose made possible a continuous bleeding during 24 to 48 hours, solely through the ungual window. Further doses were applied based on the degree of congestion of the replanted digit, but usually it was necessary to infiltrate up to 500 units of heparin every 24 to 48 hours until vascular stability was achieved. Three patients were treated with this technique. One opted for quitting the treatment. A replanted thumb suffered venous congestion on the seventh postoperative day and was treated with local subcutaneous heparin for 3 days. A replanted fingertip suffered venous thrombosis 24 hours after surgery and was treated likewise for 18 days. In these two patients, success was attained. blood transfusions were carried out in the latter two, and none had any systemic changes in partial thromboplastin or thrombin time. This treatment is based on the mechanism of action of heparin at high doses but applied only to the congested segment. Besides their anticoagulant effect through antithrombin, high doses of heparin slow platelet aggregation, may induce angiogenesis, and have a longer-than-normal half-life. With the above technique, heparin has been applied to the congested segment at an approximate dose of 33,000 to 40,000 units/kg, and continuous bleeding solely through the ungual window for 24 to 48 hours has been achieved, which has allowed us to save two replanted segments with no complications at all. This method may offer another alternative for the medical treatment of venous insufficiency in replanted segments. ( info) |
5/137. Reverse venous outflow of a free fibular osteocutaneous flap: a salvage procedure. The authors report 2 patients with a massive bony defect of the tibia due to chronic osteomyelitis. They reconstructed the defect using a free vascularized fibular osteocutaneous flap. Unfortunately, venous insufficiency was diagnosed 24 hours postoperatively. The previous anastomosed veins were promptly explored. The peroneal veins of the vascularized fibular bone graft were noted to be full of thrombi. After thrombectomy, the vessels became very fragile and broke down easily. It was impossible to achieve normal antegrade venous outflow from the previous vein of the donor graft; however, they found that distal runoff of the peroneal vein achieved a reverse venous outflow from the donor graft. The great saphenous vein was dissected and reanastomosed to achieve adequate venous drainage. This procedure may offer an alternative treatment for a flap with venous insufficiency. ( info) |
| Venous hypertension with subsequent chronic venous insufficiency and its sequelae in the hand is reported as an uncommon complication of arteriovenous fistulae for hemodialysis. ( info) |
7/137. Lipodermatosclerosis - report of three cases and review of the literature. We report 3 cases of lipodermatosclerosis (LDS) and discuss the nosology of similar disorders caused by venous insufficiency of the legs. These cases are characterized by (1) occurrence in middle-aged or aged woman, (2) painful, indurated erythema with hyperpigmented scleroderma-like hardening on the lower leg, (3) lobular panniculitis with membranocystic fat necrosis and various degrees of septal fibrosis. Although the designation LDS has been used particularly in the UK and in the USA, this entity is not familiar in other countries including japan. LDS clinically represents a wide spectrum from an acute, inflammatory phase to a chronic, fibrotic state. The clinicopathologic findings of LDS are similar or identical to the disease previously reported as chronic indurated cellulitis, hypodermitis sclerodermiformis, stasis panniculitis or sclerosing panniculitis. These diseases are probably related conditions, which depend upon the various stages. ( info) |
8/137. Chronic leg ulcers: types and treatment. Disorders of the arteries, veins, or nerves, alone or in combination, can result in leg ulcers. The presentation in these cases varies with the cause, which in turn guides management. A differential diagnosis is critical, because treatment that is essential for one type of ulcer may be contraindicated in another. ( info) |
9/137. Renal transplantation in patients with complete obstruction of the inferior vena cava. We describe 2 patients with end-stage renal disease who had complete obstruction of the inferior vena cava and were successfully treated with renal transplantation in the usual iliac fossa position. One patient is doing well, with normal renal function more than 20 years after transplantation; the other patient was lost to follow-up after 3 months. Despite some technical difficulties, these patients apparently do well provided that an adequate collateral circulation bypassing the obstruction is confirmed by venography, and the patients receive anticoagulant therapy indefinitely. ( info) |
10/137. Recurrent varicose veins of both lower limbs due to bilateral ovarian vein incompetence. A case of a 43-year-old female patient with mild pelvic pain and bilateral recurrent varicose veins due to incompetence of both ovarian veins is presented here. Ovarian vein incompetence was suspected from the presence of vulva varicosities and was confirmed by transvaginal ultrasound and descending ovarian venography. Treatment with transcatheter embolization of the ovarian veins was followed by local excision of the leg varices. Four years later, the patient remains asymptomatic and without any recurrence of varicose veins in both lower limbs. ( info) |