Thesis (M.App.Sc. in Physiotherapy)--University of South Australia, 1997.

Abstract The purpose of the present research was (I-II) to evaluate the effects of clinical, hand-held Doppler (HHD) and duplex ultrasonographic examinations on the planning of operative procedure for primary varicose veins, (III) to assess the feasibility, safety and efficacy of endovenous saphenous vein obliteration with radiofrequency-resistive heating and (IV) to compare endovenous saphenous vein obliteration with conventional stripping operation in terms of short-term recovery and costs. Sixty-two legs (in 49 consecutive patients) and 142 legs (in 111 consecutive patients) with primary uncomplicated varicose veins were examined clinically and with HHD and duplex ultrasonography for planning the subsequent treatment. At the saphenous-femoral junction (SFJ) and at the saphenous-popliteal junction (SPJ), sensitivity was 56-64% and 23%, specificity 93-97% and 96%, positive predictive value 97-98% and 43% and negative predictive value 44-45% and 91%, respectively. In 9% of the cases, the treatment plan was modified on the basis of the duplex ultrasound findings. The present study showed that, in primary uncomplicated varicose veins, the accuracy of HHD is unsatisfactory. Thirty legs of 27 patients with varicose veins were treated using an endovenous catheter (Closure® System, VNUS Medical Technologies, Inc., Sunnyvale, CA), which was inserted under ultrasound guidance via a percutaneous puncture or a skin incision. The persistence of vein occlusion and complications potentially attributable to the endovenous treatment were assessed at 1-week, 6-week, 3-month, 6-month and 1-year follow-up visits. By the time of the last follow-up visit, occlusion of the treated segment of the LSV had been achieved in 22 (73.3%) legs. Persisting patency or recanalization of LSV was detected in 8 legs (26.7%). Postoperative complications included saphenous nerve paresthesia in 3 legs (10%) and thermal skin injury in one limb (3.3%). Twenty-eight selected patients admitted for operative treatment of varicose veins in the tributaries of the primary long saphenous were randomly assigned to endovenous obliteration (n = 15) or stripping operation (n = 13). The patients were followed up for 7-8 weeks postoperatively and examined by duplex ultrasonography. The comparison of costs included both direct medical costs and costs due to lost of productivity. All operations were successful, and the complication rates were similar in the two groups. The sick leaves were significantly shorter in the endovenous obliteration group [6.5 (SD 3.3) vs. 15.6 (SD 6.0), 95 % CI 5.4 to 12.9, p < 0.001, t-test]. When the value of the lost working days was included, the endovenous obliteration was societally cost-saving.

Renal hypoperfusion from renal artery stenosis (RAS) activates the renin-angiotensin system, which in turn causes volume overload and hypertension. Atherosclerosis and fibromuscular dysplasia are the most common causes of renal artery stenosis. Recurrent flash pulmonary edema, also known as Pickering syndrome, is commonly associated with bilateral renal artery stenosis. There should be a high index of clinical suspicion for renal artery stenosis in the setting of recurrent flash pulmonary edema and severe hypertension in patients with atherosclerotic disease. Duplex ultrasonography is commonly recommended as the best initial test for the detection of renal artery stenosis. Computed tomography (CT) angiography (CTA) or magnetic resonance (MR) angiography (MRA) are useful diagnostic imaging studies for the detection of renal artery stenosis in patients where duplex ultrasonography is difficult. If duplex ultrasound, CTA, and MRA are indeterminate or pose a risk of significant renal impairment, renal angiography is useful for a definitive diagnosis of RAS. The focus of medical management for RAS relies on controlling renovascular hypertension and aggressive lifestyle modification with control of atherosclerotic disease risk factors. The restoration of renal artery patency by revascularization in the setting of RAS due to atherosclerosis may help in the management of hypertension and minimize renal dysfunction.

We prospectively evaluated 30 consecutive patients with echo-enhanced transcranial color-coded duplexsonography (TCCD) and correlative transfemoral digital subtraction angiography to assess the diagnostic efficacy of echo-enhanced TCCD for evaluation of collateral pathways through the circle of Willis in patients with limited acoustic bone windows and critical symptomatic carotid disease. Echo-enhanced TCCD detected collateral blood flow through the anterior communicating artery in 16 of 18 patients (sensitivity 89%, 95% CI 65–99%) and was false positive in one out of 12 patients without collateral flow (specificity 92%, 95% CI 59–100%). For the posterior communicating artery, sensitivity was 11/14 (79%, 95% CI 49–95%) and specificity was 15/16 (94%, 95% CI 70–100%). Echo-enhanced TCCD enables to study collateral blood flow through the communicating arteries of the circle of Willis with high sensitivity and specificity in patients with obstructions of the internal carotid artery and limited acoustic bone windows. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

We prospectively evaluated 30 consecutive patients with echo-enhanced transcranial color-coded duplexsonography (TCCD) and correlative transfemoral digital subtraction angiography to assess the diagnostic efficacy of echo-enhanced TCCD for evaluation of collateral pathways through the circle of Willis in patients with limited acoustic bone windows and critical symptomatic carotid disease. Echo-enhanced TCCD detected collateral blood flow through the anterior communicating artery in 16 of 18 patients (sensitivity 89%, 95% CI 65–99%) and was false positive in one out of 12 patients without collateral flow (specificity 92%, 95% CI 59–100%). For the posterior communicating artery, sensitivity was 11/14 (79%, 95% CI 49–95%) and specificity was 15/16 (94%, 95% CI 70–100%). Echo-enhanced TCCD enables to study collateral blood flow through the communicating arteries of the circle of Willis with high sensitivity and specificity in patients with obstructions of the internal carotid artery and limited acoustic bone windows. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.