A Possible Role for Arterial Duplex and Hand Acceleration Time in Diagnosing and Managing Shock

INTRODUCTION In 1999, a survey was published detailing the management of varicose veins by members of the then Vascular Surgical Society (VSS). Since then, newer methods for treating varicose veins have been developed and far more explicit rationing has been introduced in the NHS. SUBJECTS AND METHODS In order to examine whether there had been a significant change in established practice in the UK, a questionnaire was sent to all Vascular Society of Great Britain and Ireland (VSGBI) members in the 2004 yearbook by E-mail or post. RESULTS Of the 426 questionnaires distributed, a 69% response rate was achieved. Of respondents, 97% treated varicose veins in their NHS practice, whilst 88% did so in private practice. Some 73% used hand-held Doppler assessment in the clinic and 96% used duplex ultrasound assessment selectively. Despite UK National Institute for Health and Clinical Excellence (NICE) guidelines, only 68% said that their primary care trusts funded treatment of symptomatic varicose veins, while 93% did so for complications. In either NHS or private practice, respectively, 83% or 72% of responders offered surgery as preferred treatment for primary varicose veins, while 14% or 20% preferred endovascular treatments (endovascular laser treatment, radiofrequency ablation and foam sclerotherapy). Of responders, 17% did not follow-up patients after treatment. CONCLUSIONS This survey suggests that there is rationing of access to care for symptomatic varicose veins. Despite publicity for endovenous techniques, surgery remains the preferred treatment for varicose veins in the UK.

SummaryClinical diagnostics of venous leg ulcers set the course for efficient therapy. Precise clinical findings with an objectification of signs and symptoms of chronic venous insufficiency are essential. Duplex ultrasound investigations of the leg veins are necessary in the very early stages after the appearance of leg ulcers. Furthermore, not only a clinical investigation of the arterial perfusion but also the determination of the ankle-brachial-index is obligatory. Microbiological diagnostics are currently seen as useful in Germany, due to discussions on MRSA, even though they don´t have an immediate therapeutic consequence without the presence of clinical signs of infection. Therapeutic achievements can be objectified by a continuous documentation of the wound size, the wound bed, the wound exudate and signs of infection as well as the life quality of patients with chronic wounds.

Objective: Evaluation of neovascularization at the saphenous ligation site as a cause of recurrent varicose veins. Design: Prospective duplex study of a single patient group. Setting: Vascular clinic of a University Hospital. Patients: 131 patients (177 limbs) were evaluated 2 and 12 months after varicose vein surgery. Intervention: Clinical assessment and colour duplex scanning of operated limbs. Main outcome measures: Limbs were classified according to the degree of neovascularization: grade 0 = no new communicating vein, grade 1 = new communicating vein with diameter <4 mm, and grade 2 = new communicating vein with diameter >4 mm and pathological reflux. Results: Two months postoperatively, grade 0 was observed in 173 limbs (98%) and grade 1 in four limbs (2%). Twelve months postoperatively, 152 limbs (86%) scored grade 0, 16 limbs (9%) grade 1 and nine limbs (5%) grade 2. Conclusions: After correctly performed previous surgery, neovascularization of varying degree may occur within 1 year, as can be demonstrated on postoperative duplex examination.

Background: Ischemia of the hand is a debilitating condition. In many cases, the cause of ischemia is diffuse atherosclerosis with no distal vessels available for bypass. In these situations, options are limited to restore perfusion, and there is a potential role for arterialization of the venous system to relieve ischemic pain and avoid amputation. Methods: This is a retrospective review of all patients at our institution who underwent arterialization of the venous system between 2010 and 2014 by 4 surgeons for acute or chronic ischemia of the upper extremity not amenable to bypass procedures. Indications, preoperative and postoperative findings, and the requirement for future digital amputations were recorded. The patients were then evaluated prospectively for the patency of arteriovenous anastomosis and the pattern of perfusion by duplex ultrasound studies. Results: Eight patients with 10 upper extremities underwent arterialization of the venous system. All patients with chronic ischemia went on to heal their ischemic ulcerations with relief of rest pain and avoided amputation. Eight upper extremities had arterial Doppler and duplex ultrasound signals showing arterialized dorsal veins demonstrating flow from the dorsal veins heading volar via the intrinsic compartments into the digital arteries. Conclusions: This study illustrates the successful use of arterialization of the venous system of the hand in both acute and chronic hand ischemia. It reports on prospective imaging and duplex ultrasound studies confirming patency of the anastomosis and objective evidence of distal arterial flow. Based on our experience, we believe that arterialization of the venous system may provide an effective salvage option in the setting where no distal bypass is available.