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03 DN 009 BA

LYMPHOLOGY

PHLEBO
N°37

XXth World Congress
of the International
Union of Angiology
7-11 April, 2002 - New York City, USA

AIMS AND SCOPE
Phlebolymphology is an international
scientific journal entirely devoted to
venous disease.
The aim of Phlebolymphology is to
provide doctors with updated and
interesting information on phlebology and lymphology written by wellknown specialists from different
countries worldwide.
Phlebolymphology is scientifically
supported by a prestigious editorial
board.
Phlebolymphology has been published four times per year since 1994,
and, thanks to its high scientific level,
was included in the EMBASE database in 1998.
Phlebolymphology is made up of
several sections: editorial, articles
on phlebology and lymphology, news,
review, and congress calendar.

Advisory board
PRESIDENT
J. A. JIMÉNEZ COSSÍO, MD
Head, Dept of Angiology and Vascular Surgery
La Paz Hospital - 28043 Madrid, Spain

MEMBERS
C. ALLEGRA, MD
Head, Dept of Angiology
Hospital S. Giovanni Via S. Giovanni Laterano, 155 - 00184, Rome, Italy

P. COLERIDGE SMITH, MD
Senior Lecturer and Consultant Surgeon University College London Medical School
The Middlesex Hospital Mortimer Street - London W1N 8AA, UK

M. COSPITE, MD
Head, Dept of Angiology
University Clinic, Palermo, Italy

G. JANTET, MD
Consultant Vascular Surgeon
Past President of the Union Internationale de Phlébologie
14, rue Duroc, 75007 Paris, France

P. S. MORTIMER, MD
Consultant Skin Physician & Senior Lecturer in Medicine (Dermatology)
St George’s Hospital - Black Shaw Road, London SW17 OQT, UK

A. N. NICOLAIDES, MD
Institute of Neurology and Genetics
6, International Airport Avenue - Ayios Dhom Ctios
P. O. Box 3462 CY 1683 Nicosia - Cyprus

H. PARTSCH, MD
President of the Union Internationale de Phlébologie
Baumeistergasse 85
A 1160 Vienna, Austria

M. PERRIN, MD
Chirurgie Vasculaire
Past President of the Société de Chirurgie Vasculaire de Langue Française
Past President of the Société Française de Phlébologie
Past President of the European Venous Forum
26, Chemin de Décines - 69680 Chassieu, France

L. THIERY, MD
Angiologist & Surgeon
Consultant, University Hospital Gent - Korte Meer 12, 900 Gent, Belgium
CITED/ABSTRACTED
IN EMBASE/Excerpta Medica
© 2002 Les Laboratoires Servier All rights reserved throughout the world
and in all languages.

V. WIENERT, MD
Head, Dept of Phlebology
University Clinic - Pauwelstrasse, 51000 Aachen, Germany

EDITORIAL
T

he 20th World Congress of the International Union
of Angiology was held in the Marriott Marquis Hotel,
New York City, USA from April 7 to 11th, 2002.
Following the tragedy of September 11th the nominated symbol of the meeting was the
Statue of Liberty which radiates the international spirit of the IUA and brings the
civilized world closer together, now more
than ever before.

judges all agreed that the final decision on the winner
was an extremely difficult one. However, it was with
general approval that the winning presentation by
Dr O Pichot on the ‘Duplex imaging analysis of the
greater saphenous vein reflux: basis
for strategy of endovenous obliteration treatment’ was both insightful
and deserved in its praise.

The sessions were centered around the many facets of
arterial disease. Discussions, in both the plenary and
free communication sessions, ranged from the aetiology, genetics and biology of vascular disease through to
new developments in medical, surgical and endovascular management of all vascular disorders.

presentations given on arterial, venous and lymphatic
diseases, and I do welcome this initiative.

There were up to 5 sessions taking
The main topics of this meeting were
place at the same time and so
focused on the multidisciplinary manageparticipants were only able to hear a
ment of vascular disease. The internasmall number of presentations. Theretional faculty featured over 200 world
fore the report by the team of the
experts in the fields of vascular medicine
Medical
Reporters’
Academy,
and biology, interventional radiology,
initiated by Servier International,
cardiology, vascular and endovascular
presents an excellent opportunity
Peter Gloviczki, MD
surgery. Plus, with more than 200 delegates
to learn from the main topics
presenting free communications or posters from
discussed during this meeting.
33 countries, the program was found to be both of high
This team, chaired by Prof Andrew Nicolaides,
scientific level and extremely relevant for daily practice.
has selected extensive information from the many

As ever the sessions on venous disease were well
attended reflecting the ever-growing interest in and
global awareness of the impact venous disease has on
our daily clinical practice.
The fiercely contested ‘IUA prize session II - venous
disease’ was one of the more memorable events. The

PHLEBOLYMPHOLOGY 2002

The meeting allowed our friends from all over the
world to meet once again and renew old acquaintances
in the breathtaking city of New York. Please enjoy the
articles in this issue and share in the pride we have for
the success of this year’s world meeting of the IUA.

Peter Gloviczki, MD
Congress Chair and President
International Union of Angiology

S1

PREFACE

M

eetings are one of the most important
way of exchanging knowledge and ideas. Since
there are many meetings organized every year
in the field of vascular diseases, it has become
quite impossible to attend all of them. A choice
has to be made relying on subsequent reports
or proceedings if one is to be kept informed.
The Medical Reporters’ Academy (MRA) was
created with an educational grant from Servier
to fill the gap. With its team of young medical
reporters from different European countries,
the MRA members were selected to attend
international conferences. During the 20th
world Congress of the IUA in New York City,
the MRA covered everyday sessions of the
congress and met at the end of the day to select
the presentations that were considered to be
news in the field of vascular diseases. In this
issue much selected information is given on

PHLEBOLYMPHOLOGY 2002

the many presentations of the congress. I hope
the readers will find this report interesting and
helpful.
Wishing you enjoyable reading.

A.N. Nicolaides
Chairman and Medical Director, The Cyprus Institute
of Neurology and Genetics
Emeritus Professor of Vascular Surgery, Imperial College
of Science, Technology and Medicine, London
Past President of the International Union of Angiology

S3

MEDICAL REPORTERS’ ACADEMY (MRA)
The reports from the European Congress of the Union Internationale de Phlébologie
were prepared by the following members of the MRA team:

Andrew NICOLAIDES
Chairman of the MRA
Institute of Neurology and Genetics
6, International Airport Avenue
Ayios Dhom Ctios
P.O. Box 23462 CY 1683
Nicosia, Cyprus

Iris BAUMGARTNER
Inselspital Bern Abteilung
Angiologie Freiburgerstrasse 4
3010 Bern, Switzerland

Yves BLOMME
Volkskliniek
Tichelrei
B-9000 Gent, Belgium

José Antonio PEREIRA ALBINO
Deputy Clinical Manager Hospital
Santa Monika R. Raquel
Roque Gameiro, n° 16a R/C Esq.
1500-540 Lisboa, Portugal

Enrique PURAS MALLAGRAY
Hospital Fundación de Alcorcón
Unidad de Cirurgía Vascular
Departamento de Cirurgía
c/ Budapest, 1
28922 Alcorcon, Spain

Andrzej GABRUSIEWICZ

Daniele RIGHI

Dept of Vascular Surgery
S. Elisabeth Hospital
1. Goszcynskeigo Str
02-616 Warszawa, Poland

Viale Mamiani, n. 24
50137 Firenze, Italy

Vassilios PAPAVASSILIOU
11, Gedeon Street
11525 Athens, Greece

Bernhard PARTSCH
Krankenhaus Lainz
Dermatologische Abteilung
Wolkersbergenstr.1
1130 Wien, Austria

S4

Patricia SENET
Hôpital Charles Foix
Pavillon de l’Orbe
7, avenue de la République
94205 Ivry-sur-Seine, France

Elena IBORRA
Ciutat Sanitaria i Universitaria
de Bellvitge
Servicio de Angiología y Cirurgía Vascular
C/ Fcixa Llarga, s/n
08907 L’Hospitalet de Llobregat, Spain

PHLEBOLYMPHOLOGY 2002

CONTENTS
Part 1
ADVANCES IN VASCULAR MEDICINE ---- S11

• Straub-Rotarex™-assisted recanalization
of in-stent occlusions of femoropopliteal arteries:
long-term results - U. Frank

FRONTIERS IN VASCULAR BIOLOGY, MEDICINE,
AND SURGERY I: A TRIBUTE TO EUGENE
STRANDNESS Jr, MD

• Percutaneous transluminal angioplasty
using gadodiamide as alternative contrast
agent in patients with contraindications
to iodine-containing contrast agents - U. Frank

• Epidemiology, cardiovascular genetics, and
ultrasound: can we bridge the gap? - A. Nicolaides

• Videoscopic methods used in sympathetic
denervations - J. Wronski

• Evaluation and contemporary treatment
of carotid artery disease - W. Baker

• The use of Doppler ultrasound in the investigation
of thoracic outlet syndrome: normative data
P. G. Byrne

• Outpatient management of venous thromboembolism - R. Hull
• Progress in surgical, endoscopic, and endovascular
treatment of chronic venous disease - P. Gloviczki
• Treatment of aortic aneurysms in the 21st century
L. Hollier
FRONTIERS IN VASCULAR BIOLOGY,
MEDICINE, AND SURGERY II
• Pharmacological and intensive care in critical
leg ischemia (CLI) - G. M. Andreozzi

Part 2
AORTIC ANEURYSMS ----------------------------------- S21
AORTIC ANEURYSMS I
ETIOLOGY, GENETICS, TREATMENT
AORTIC ANEURYSMS II

FRONTIERS IN VASCULAR BIOLOGY,
MEDICINE, AND SURGERY
• The pathobiology of atherosclerosis:
morphological and clinical relevance - A. Kádár

• What is the best technique to image abdominal
aortic aneurysms for open surgical repair, and
what is the best for endovascular stent-grafts?
M. Fillinger

NEW DEVELOPMENTS IN VASCULAR BIOLOGY

AORTIC AND PERIPHERAL ANEURYSMS

• Keynote Address: New roles for the tissue factor
pathway in vascular disease - R. Simari

• Abdominal aortic surgery through
a minilaparotomy - T. Klokocovnik

NEW TECHNIQUES AND NEW TECHNOLOGY
IN VENOUS DISEASE
• High ligation and stripping is the gold standard
for treating varicose veins - J. Corson
• Initial results of polidocanol microfoam treatment
of saphenous incompetence - C. McCollum

• Abdominal aortic aneurysm surgery through
a small retroperitoneal incision - A.Lederman
• What is the future for minimally invasive
technology for aortic surgery? - Y. Dion
• Popliteal aneurysms: a 20-year experience
C. Zorzoli

• Ablation of superficial reflux with radiofrequency
and laser - N. Morrison

AORTIC ANEURYSMS AND DISSECTIONS:
OPEN OR ENDOVASCULAR REPAIR?

NEW TECHNOLOGY, THORACIC OUTLET
SYNDROME

• Keynote lecture: The natural history of thoracoabdominal aortic aneurysms and the effectiveness
of surgical treatment - H. Safi

• Straub-Rotarex™-assisted recanalization
of thrombotic/embolic arterial occlusions:
long-term results - U. Frank
PHLEBOLYMPHOLOGY 2002

• The use of 3D imaging and volume measurements
for endograft surveillance - H. Beebe

S5

• Open or endovascular repair of abdominal
aortic aneurysms? Current practice at the
Mayo Clinic - P. Gloviczki

• The incidence of carotid artery disease:
lessons learned from the Cyprus carotid study
N. Angelides

• Open or endovascular repair of type B
aortic dissections? Current practice
at the Cleveland Clinic - R. Greenberg

• Intraoperative hemodynamic assessment
following carotid endarterectomy experience
with a new, angle-independent Doppler
T.E. Rasmussen

• Results of the US experience with the Gore
Excluder bifurcated endoprosthesis - T. Sullivan
• Results of the US Pivotal trial of the Talent LPS
Stent-graft for repair of AAAs - F. Criado
• Long-term results with the EVT/Ancure
Endograft System for repair of AAAs - W. Moore

• Keynote Lecture: The state of the art of carotid
stenting - R. Hobson
• Endoluminal surgical treatment of common
carotid artery disease - J. M. Cormier

AORTIC ANEURYSMS: ENDOVASCULAR REPAIR

CEREBROVASCULAR DISEASE II: MEDICAL,
SURGICAL, AND ENDOVASCULAR TREATMENT

• Keynote address: The Montefiore experience
with endovascular repair of elective and ruptured
abdominal aortic aneurysms (AAA) - F. Veith

• Conventional carotid endarterectomy
and venous patch angioplasty: the gold
standard - E. Bastounis

• Is percutaneous endograft placement possible,
and what is the benefit of intravascular
ultrasound? - R.White

• Conventional endarterectomy with bovine
pericardium patch: a comparison with polyester
patch angioplasty - A. Oldenburg

• Lessons learned from the EUROSTAR registry
on endovascular repair of abdominal aortic
aneurysms - J. Buth

• Eversion carotid endarterectomy gives
the best long-term surgical results - D.Shah

• Long-term results of endovascular treatment
of abdominal aortic aneurysms:
the Cleveland clinic experience - K. Ouriel

• Keynote Lecture: Asymptomatic carotid lesions
are markers of future cerebrovascular and
cardiovascular events: what should we do?
S. Novo
CEREBROVASCULAR DISEASE III

Part 3
ATHEROSCLEROSIS --------------------------------------- S31
RISK FACTORS OF ATHEROSCLEROSIS
• Keynote Lecture: Global cardiovascular risk in
patients with peripheral arterial diseases - S. Novo
• What techniques have been effective
at the Mayo clinic to stop smoking? - R. Hurt
• Optimizing adherence to smoke cessation
in vascular disease patients: is this possible?
The Canadian perspective - J. Irvine

• Ultrasonic texture analysis and symptoms
A. Nicolaides
• Carotid plaque at risk for ischemic
cerebrovascular events - A.Visona
• Why is conventional carotid endarterectomy
the best treatment for carotid artery disease?
T. Riles
• Why is surgical treatment superior to carotid
stenting? - J. Fernandes e Fernandes
• The current state and future prospects
of carotid stenting - J. Parodi

Part 5
Part 4
CEREBROVASCULAR DISEASES --------------- S33

CHRONIC VENOUS DISEASE ---------------------- S41
NEW DEVELOPMENTS IN THE MANAGEMENT
OF CHRONIC VENOUS DISEASE

CEREBROVASCULAR DISEASE I

• The role of elastic compression stockings in the
treatment of chronic venous disease - H. Partsch

• Conventional endarterectomy of the carotid
arteries is a safe, effective, and durable
procedure - G. Deriu

• The effectiveness of compression treatment
with bandaging in the treatment of severe
chronic venous insufficiency - K. Burnand

S6

PHLEBOLYMPHOLOGY 2002

• New technology for local treatment of venous
ulcers - G. Moneta

• Pathophysiology of venous ulcers
M. De Castro Silva

• Current surgical treatment of varicose veins
and saphenous incompetence - H Schanzer

• Radiofrequency treatment for perforator
surgery - J. Ulloa

• Endovenous treatment of superficial
incompetence - J. Bergan
• Evidence for effectiveness of deep vein valve
reconstruction - M. Perrin

Part 6

• Surgical reconstruction for iliofemoral
and inferior vena caval occlusions - P. Gloviczki

CONSENSUS MEETINGS ------------------------------- S53

CHRONIC VENOUS DISEASE

RECENT CONSENSUS DOCUMENTS
AND THEIR PROSPECTS: TASC AND CoCaLIs

• Bonn Vein-Study, epidemiologic study
on the prevalence and risk factors of chronic
venous diseases - E. Rabe

• TASC
• CoCaLIs

• Patterns of venous reflux in patients
presenting with varicose veins - J. P. Fletcher
• Linear morphea after surgery of the saphenous
veins - C. Ponca
CHRONIC VENOUS DISEASE
AND VENOUS ULCERS
• Conservative versus SEPS treatment of venous
stasis ulcers - D. Krievins
• Healing process of venous ulcers: involvement
of microcirculation - M. E. Gschwandtner
• The use of cellulose membrane in the treatment
of venous leg ulcers - M. Kucharzewski
VASCULAR MALFORMATIONS
AND CHRONIC VENOUS DISEASE
• Prevention of neoangiogenesis after crossectomy
by implanting a Goretex plastic tube: 18-month
results - K. Selzle
• The laparoscopic diagnosis of pelvic
varicose veins - M. L. Pavkov
• Diagnostic approach to peripheral venous
malformations: the roles of MRI and Duplex
scanning - B. B. Lee
CHRONIC VENOUS DISEASE
AND VENOUS MALFORMATIONS
Organized by the IUA and the American, South
American, and Latin-American Venous Forums

Part 7
IUA PRIZE ---------------------------------------------------------- S57
ABSTRACTS PRESENTED BELOW ARE
THOSE BY THE THREE FINALISTS
OF THE IUA FELLOWSHIP
• Duplex imaging analysis of greater
saphenous vein reflux: basis for strategy
of endovenous obliteration treatment - O. Pichot
• Potential use of D-dimer measurement
in patients treated with oral anticoagultants
for a venous thromboembolic episode
E. Ombandza-Moussa
• Duplex ultrasound criteria for defining
the severity of carotid stenosis - K. A. Fillis

Part 8
LYMPHOLOGY-------------------------------------------------- S61
LYMPHEDEMA AND CHYLOUS DISORDERS
• Microcirculation and lymphedema - G. Thibaut
• Nonoperative treatment of chronic
lymphedema - T. Rooke

• Long-term results of high ligation and stripping
of the great saphenous vein - E. Enrici

• Surgical treatment of chronic lymphedema
K. Burnand

• Long-term results of high ligation without
stripping of the great saphenous vein - A. Shapira

• Surgical treatment of primary chylous
disorders - P. Gloviczki

• Surgical treatment of patients with
Klippel-Trenaunay syndrome - R. Simkin

• Long-term results of lymph vessel transplantation
for chronic lymphedema - R. Baumeister

• Subfascial endoscopic perforator surgery:
the Brazilian experience - A. Lederman

• The state of the art of lymphatic microsurgery
C. Campisi

PHLEBOLYMPHOLOGY 2002

S7

Part 9
PERIPHERAL ARTERIAL DISEASE----------- S65
DIABETES, CRITICAL LIMB ISCHEMIA,
AMPUTATION
• Carotid artery atherosclerosis according
to the ACE I/D polymorphism in subjects
with diabetes mellitus - E. Andreadis
PATIENTS WITH PERIPHERAL ARTERIAL DISEASE
AND CHANGES IN THE UPPER-LIMB VESSELS
• Intimal thickening of the radial artery - J. Woodcock
PERIPHERAL ARTERIAL DISEASE: EPIDEMIOLOGY,
QUALITY OF LIFE, MEDICAL TREATMENT
• Legs for Life: a screening and educational
program for vascular disease - P. Beatty
• Disease-specific quality of life (QOL) analysis:
is it necessary in patients with claudication?
P. A. Coughlin
PHARMACOTHERAPY FOR PERIPHERAL
ARTERIAL DISEASE
The 3rd transatlantic vascular medicine
symposium
VASCULAR BIOLOGY
• The prevalence and natural history of PAD:
A rationale and primer for PAD
pharmacotherapy - J. Dormandy
• Pathophysiology of claudication - W. Hiatt
• Measuring clinical outcomes: claudication
(Report of the transatlantic Guidelines)
K. H. Labs
• Measuring clinical outcomes: CLI (Report
of the transatlantic Guidelines) - F. Moneta
ESTABLISHED THERAPIES FOR CLAUDICATION
• Role of lifestyle and exercise interventions
A.Hirsh

• Introducing controlled outpatient management
(COM) of deep venous thrombosis in Germany –
a feasibility study with 827 patients - H. E. Gerlach
• Outpatient treatment of deep vein thrombosis:
selection of patients and management
of symptoms with leg compression –
a feasibility study - W. Blättler
• Venous thromboembolism and cancer –
new insights? - V. Kakkar
• Low-molecular-weight heparins –
clinical trial update - S. Haas
NEW DEVELOPMENTS IN THE MANAGEMENT
OF THROMBOTIC AND VASCULAR DISORDERS I
• Newer concepts in the understanding
of thrombosis; impact on anticoagulant therapy
J. Fareed
• TFPI as a novel antithrombotic agent
D. Hoppensteadt
• AXa drugs and antithrombotics: replacement
of heparin - B. Kaiser
• A survey of antithrombin agents for the
prophylaxis and treatment of thrombosis
S. Haas
• Warfarin oral thrombin inhibitors and LMW
heparins: which is the best? - R. Hull
• DVT and pulmonary embolism: what are
the current guidelines? - S. Goldhaber
NEW DEVELOPMENTS IN THE MANAGEMENT
OF THROMBOTIC AND VASCULAR DISORDERS II
• Current concepts in the management of heparininduced thrombocytopenia - J. Walenga
• Antiplatelet drugs in vascular medicine
and surgery: the real role of aspirin - H. K. Breddin
NEW DEVELOPMENTS IN THROMBOSIS
MANAGEMENT II

• Role of revascularization in the treatment
of claudication - M. Jaff

• Anticoagulant and bleeding effects of low
molecular weight heparins at surgical
and interventional dosages can be effectively
neutralized by heparinase - O. Iqbal

Part 10

• Heparinase as an antagonist to prevent
hemorrhagic complications involved
with heparins and other heparin-derived
oligosaccharides - O. Iqbal

THROMBOTIC DISORDERS ------------------------- S75
CURRENT ASPECTS OF DEEP VEIN
THROMBOSIS

• Turbulent flow of plasma promotes
thrombolysis of nonocclusive blood clots –
A MRI study in vitro - A. Blinc

• Leg compression and ambulation are better
than bed rest for the treatment of symptoms
of acute proximal deep vein thrombosis
H. Partsch

REDEFINING THE MANAGEMENT
OF THROMBOTIC DISORDERS:
ROLE OF SELECTIVE FACTOR Xa INHIBITION

S8

PHLEBOLYMPHOLOGY 2002

COMBINED DRUG THERAPY
IN THE MANAGEMENT OF THROMBOSIS
• Keynote Lecture: Antiphospholipid syndrome
and vascular diseases - R. Bick
ACUTE DEEP VEIN THROMBOSIS I
• Genetic factors of venous- thromoboembolism
and their consequences - J. Emmerich
• Strategies for the diagnosis of acute
venous -thromboembolism - A. Perrier
• Acute treatment of venous thromboembolism
G. Meyer
• Duration of treatment after deep vein
thrombosis - S. Schulman
• Keynote lecture: Quality management
in venous thromboembolism - P. Carpentier
NEWER CONCEPTS IN THROMBOGENESIS
• Effect of LMWH and different heparin molecular
weight fractions on aggrecanase activity:
structure-function relationships - S. A. Mousa
• Reversal of the inhibitory efficacy of heparin
on endothelial cell tube formation- induced
by FGF2 or TF/VIIa by anti-TFPI - S. A. Mousa
THROMBOSIS/HEMOSTASIS THERAPEUTIC
ADVANCES
• Bilateral deep vein thromboses of the calf
are not of minor importance - C. Seinturier
NEW DATA ON DIAGNOSIS, PREVENTION,
AND TREATMENT OF DEEP VEIN THROMBOSIS
• Venous thromboembolism and fractured neck
of femur - K. Hitos
• Deep vein thrombosis in elderly rehabilitation
patients: prevalence, risk factors, and prevention
M. A. Sevestre
• Objective end points in clinical trials in patients
with acute DVT - H.K. Breddin
EXTENDED AIR TRAVEL
AND DEEP VEIN THROMBOSIS

Part 11
VASCULAR SURGERY --------------------------------- S101

• Cell source and cell kinetics in venous stenoses
caused by polytetrafluoroethylene (PTFE)
hemodialysis grafts in experiments - S. Misra
• Results of a multi-center study comparing
vascular clip (VCS) and suture anastomosis
for hemodialysis access - A. Miller
• Multicenter evaluation of a polyurethaneurea
(PVAG) vascular access graft as compared
with the ePTFE vascular access graft in
hemodialysis:Performance of graft with
surgical intervention versus percutaneous
method - M.H. Glickman
• Treatment of angioaccess-induced hand
ischemia by the distal revascularisation-interval
ligation (DRIL) procedure: a prospective
analysis of 15 cases - C. Sessa
• Multicenter evaluation of a polyurethaneurea
(PVAG) vascular access graft as compared
with the ePTFE vascular access graft
in hemodialysis: performance of graft
with surgical intervention versus percutaneous
method - M. H. Glickman
ENDOVASCULAR AND SURGICAL TREATMENT
OF LOWER-EXTREMITY ISCHEMIA
• Challenges of peripheral endovascular
therapy in Egyptian and North African patients
E. Hussein
• Combined endovascular and open surgical
treatment for lower-extremity occlusive
arterial disease - K. Calligaro
• Does carbon improve performance
of PTFE bypass material? - X. Kapfer
• Early results of the Distaflo randomized
trial for critical limb ischemia - J. Panneton
• Infrainguinal revascularization without
arteriography: the Italian experience - F. Spinelli
• Infrainguinal revascularization with duplex
arteriography: the Maimonides experience
E. Ascher
• Challenges of inframalleolar revascularizations:
long-term results with pedal bypass - T. Bower
AORTIC SURGERY: CHALLENGES
AND INFECTIOUS COMPLICATIONS
• Inflammatory abdominal aortic aneurysms: new
data on pathogenesis and management - P. Fiorani
• Combined abdominal aortic aneurysmectomy
and other abdominal operations - E. A. Bastounis

VASCULAR ACCESS

• A 10-year experience of surgery for aortoiliac
occlusive disease - M. M. Fett

• An all- autologous policy for vascular access
A. Hingorani

• Infected aortic aneurysms: in situ reconstruction
is a safe and durable option - G. S. Oderic

PHLEBOLYMPHOLOGY 2002

S9

• Aortic reconstruction in infected fields:
early results of the United States Cryopreserved
Aortic Allograft (USCAA) Registry - A. A. Noel
NEW TECHNOLOGY FOR MINIMALLY INVASIVE
VASCULAR RECONSTRUCTIONS

• The natural history of renal artery stenosis
and medical treatment of renovascular
hypertension - S. Textor
VASOSPASM, INFLAMMATION,
AND INFECTION IN VASCULAR DISEASE
• Currrent management of Raynaud’s syndrome:
an overview - R. Shepherd

Part 12

• Digital necrosis of the upper limb: a retrospective
study of 278 cases - U. Michon-Pasturel

VASCULAR DISEASES -------------------------------- S111
VASCULAR MALFORMATIONS
RENOVASCULAR HYPERTENSION
• Diagnosis and management of acute thromboembolism: past, present, and future - V. V. Kakkar
• Renal artery stent placement: clinical outcomes
and complications - M. McKusick
• Surgical treatment of renal artery disease;
current indications and results - R. Cambria

S10

• Vestigial marginal vein: surgical treatment
of 56 cases - J. F. Cormier
• Keynote address: Multidiciplinary management
of vascular malformations - B. B. Lee

INDEX --------------------------------------------------------------- S117

PHLEBOLYMPHOLOGY 2002

Part 1

ADVANCES IN
VASCULAR MEDICINE

FRONTIERS IN VASCULAR BIOLOGY, MEDICINE,
AND SURGERY I
A TRIBUTE TO EUGENE STRANDNESS JR, MD
Moderators: P. GLOVICZKI, (USA) and D. CLEMENT (Belgium)
Two years before Dr Strandness died, he was named Honorary President
of The 20th World Congress of the IUA.
This session was held as a tribute to Dr Strandness, and started with a presentation given
by Dr Marc Meissner about the professional achievements and literature contributions
made by Dr Strandness.

Epidemiology, cardiovascular genetics, and ultrasound:
can we bridge the gap?
A. NICOLAIDES (Cyprus)

In recent years, several studies such as the PROCAM
or Framingham studies, done in a prospective manner,
had provided us with the possibility of obtaining a way
to calculate the risk of developing a cardiovascular
event. Although high-risk groups can be identified, at
best they contain only 40% of the cardiovascular
events that will occur in the next 5 to 10 years. Prevention must be considered more cost-effective than
treatment in the setting of many cardiovascular diseases, and therefore the scientific community must
drive its efforts in this direction.
Recently, high-resolution ultrasound has been successful in identifying high-risk patients. The ARIC
study was the first to call our attention to the significance of the measurement of intima-media thickness,
and its relationship to cardiovascular morbidity. More
recently, G. Belcaro1 has pointed out that the possibility of developing a cardiovascular event is more related
to the presence of preclinical atherosclerosis plaques
than to the predicted numbers obtained from the classical risk formulas.

S12

Current knowledge in genetics is continuously
expanding, providing us with new polymorphisms that
will provide answers to many unresolved questions in
arteriosclerosis and why patients develop premature
arteriosclerosis, increased intima media thickness,
unstable plaques on ultrasound, myocardial infarction,
or stroke.
Ultrasound can give us a redefined phenotype to study
the significance of gene polymorphisms. Prof Nicolaides pointed out the importance of some of the genes
related to the cardiovascular field and their different
polymorphisms, a field that he and his group are investigating. Among other things, he showed the MMP3,
MTHFR, or ApoE polymorphisms that will have important implications in terms of selecting patients for the
new concept of targeted therapy against arteriosclerosis development.
Reference
1. Belcaro G, Nicolaides AN, Ramaswami G, et al. Arteriosclerosis.
2001;156:379-387.

PHLEBOLYMPHOLOGY 2002

Evaluation and contemporary treatment of carotid artery
disease
W. BAKER (USA)

In his presentation W. Baker reviewed current practices in his institution in terms of carotid artery surgery.
He also presented the different morphological aspects
of carotid plaques and the importance that this could
have in selecting patients for surgery. The main ideas
generated in the talk were:
• The majority of this surgery is done on the basis of
preoperative ultrasound.

• There is a need for a continuous quality assurance
program in the vascular laboratory that evaluates
patients with carotid artery disease.
• The use of intraoperative ultrasound is the preferred
method for surgical quality control.
• 40% of patients can be discharged on the same day
as the surgery.

Outpatient management of venous thromboembolism
R. HULL (Canada)

Treatment of deep venous thrombosis (DVT) in the
lower extremities has changed since the introduction
of low-molecular-weight heparins (LMWH). In general these drugs have better bioavailability, a longer
half-life, and a more predictable anticoagulant
response, with dosage based on patient weight and not
needing laboratory monitoring. Their efficacy and
safety in treating patients in an out-of-hospital setting
have been evaluated in several studies. In shortterm- use, LMWH have been shown to be at least as
effective and safe as intravenous unfractionated
heparin in the treatment of acute proximal DVT.
Studies comparing subcutaneous LMWH with
unfractionated heparin reveal similar rates of recurrent

PHLEBOLYMPHOLOGY 2002

venous thromboembolism and major bleeding outcomes. But there is still some resistance to sending
patients home for treatment.
The possibility for treating these patients with longterm LMWH instead of oral anticoagulants was also
pointed out, with recent data showing fewer side
effects and better patient tolerance in terms of quality
of life. There is also evidence that patients treated with
long-term LMWH for DVT had less incidence of
posthrombotic syndrome. The possible rebound
phenomenon of an increased incidence of new DVT
after cessation of long-term therapy with LMWH
remains an important issue.

S13

Progress in surgical, endoscopic, and endovascular treatment
of chronic venous disease
P. GLOVICZKI (USA)

The contemporary management of chronic venous
insufficiency (CVI) brings together a number of different medical and surgical approaches that were
reviewed in P. Gloviczki’s presentation.
Surgical treatment of CVI is focused on correction of
the incompetent superficial venous system in most
patients, high ligation and stripping of the greater
saphenous vein (GSV) being the most prevalent
method of treatment. Other modern modalities which
have appeared in recent years include:
• Ablation of the GSV with radio frequency;

The SEPS procedure combined with the previous
therapies also provides the possibility of treating
patients with stages C5 and C6, with minimal surgical
morbidity. The data provided by the speaker showed
that the current percentage of patients treated with
SEPS is around 11% at the Mayo Clinic with an ulcer
recurrence rate at 3 years of 20%, increasing to 27%
at 5 years. The worst results are obtained when the
SEPS procedure is applied to patients with postphlebitic syndrome with a 56% ulcer recurrence rate
on follow-up.

• Laser treatment of the GSV and collaterals;
• Foam sclerotherapy under ultrasound control.

Treatment of aortic aneurysms in the 21st century
L. HOLLIER (USA)

The prevalence of aortic aneurysms is greater than
6% in the population older than 65 years. Many of
these patients are denied surgery because of high-risk
comorbidities.
In this group at least a third will die of rupture of their
aneurysms. In recent years, the advent of endovascular techniques has evolved, and permits the treatment
of increasing numbers of patients with abdominal or
thoracic aneurysms, even the high-risk group. In L.
Hollier’s experience the percentage of patients treated
with this technology reaches 80%, with the use of
commercial and self-made prostheses. A point was
made to consider this technology complementary to a

S14

surgical technique in some compromised situations,
like the second stage of the elephant trunk technique
for the treatment of thoracic aortic aneurysms, where
the extension into the thoracic aorta can be performed
with a thoracic stent.
The future scenario for vascular surgery in the next 10
to 15 years was the subject at the end of the presentation. In L. Hollier’s opinion, many surgical techniques
in the field of vascular surgery will be performed with
endovascular strategies, and vascular surgeons must
closely observe these changes and incorporate them
into their everyday practice.

PHLEBOLYMPHOLOGY 2002

FRONTIERS IN VASCULAR BIOLOGY,
MEDICINE, AND SURGERY II
Chairmen: P. GLOVICZKI (USA), S. NOVO (Italy)

Pharmacological and intensive care in critical leg ischemia (CLI)
G. M. ANDREOZZI (Italy)

Critical leg ischemia (CLI) is associated with a high

Iloprost® infusion, local or general analgesia, fluid
balance, hyperbaric oxygen, and surgical wound
debridement. Maintenance therapy includes antithrombotic drugs, oral anticoagulation, and metabolic
drugs for claudication and analgesia. The results of this
strategy, with 6 months’ follow-up, were presented
(Figure 1). Studies are needed to compare cost, quality
of life and decision of the patient regarding the two
other options for CLI not suitable for surgery: heel
salvage and long-term care versus amputation and
rehabilitation.

risk of amputation. The first therapeutic option is surgical revascularization. Sometimes, because of poor
runoff, increased prevalence of aged patients, or
increased comorbidity, bypass surgery presents a high
risk of failure, and only intensive medical care can be
performed. In CLI, most studies report pharmological
treatments carried out only once during 3 or 4 weeks,
without any data about long-term follow up to
6 months. Intensive medical care of CLI includes:
unfractionated heparin administration, PGE1 or

CLI not suitable
for surgery 

7.4%
Amputations 

62.9% Stable PAD
(± minor amputations) 

Maintenance
therapy
14.8%
Surgical revascularization  

29.6%
Persistent CLI   

14.8%
2nd Cycle of PGE1

7.4%
Amputations  

3.7%
Deaths

3.7%
Stable PAD

Stable PAD

Figure 1. Management strategies for CLI.

PHLEBOLYMPHOLOGY 2002

S15

FRONTIERS IN VASCULAR BIOLOGY,
MEDICINE, AND SURGERY
Moderators: J. JACOBSON (USA) and J. BERGAN (USA)

The pathobiology of atherosclerosis: morphological
and clinical relevance
A. KÁDÁR, T. GLASZ (Hungary)

The morphological study of arterial tissue obtained
from autopsies done in a young population dead from
external causes, has provided us with the concept that
arteriosclerosis starts in the first decades of life, and
progresses during the decades thereafter. The classification of the arterial lesions is well developed, and
starts with the so-called intimal plaque, that is, accumulation of cells in the subintimal space. This phenomenon is developed after the endothelial dysfunction is established due to external risk factors such as
hypertension, tobacco, hypercholesterolemia, and
others. There is also a genetic predisposition to develop
endothelial dysfunction in subjects with hereditary
hyperhomocystinemia, family hypercholesterolemia,
alterations in the LDL receptors, and others. The

S16

proliferation of smooth muscle cells and the presence
of inflammatory cells like T- and B-lymphocytes or
macrophages derived from the blood monocyte are the
next steps in the development of the arterial plaque
and constitute the antinflammatory response of the
arterial wall. A. Kádár stressed the presence of
Chlamydia Pneumoniae antigens in arterial lesions. As
she pointed out from the group studies, these antigens
are more prevalent in patients with hypertension and
tobacco use. There is a need to progress in the study of
the sequence in the evolution of the arteriosclerosis in
order to slow its progression, select optimal therapies,
and prevent plaque complications and their consequences.

PHLEBOLYMPHOLOGY 2002

NEW DEVELOPMENTS IN VASCULAR
BIOLOGY
Moderators: P. VANHOUTTE (France) and J. SHEPHERD (USA)

Keynote Address: New roles for the tissue factor pathway
in vascular disease
R. SIMARI (USA)

Tissue

factor (TF) is a low-molecular-weight
glycoprotein and a subendothelial procoagulant that is
considered a major regulator of arterial thrombogenicity, and tissue factor pathway inhibitor (TFPI) is a
physiological inhibitor of TF-induced coagulation that
binds to factor Xa and the TF-FVIIa complex; biologically active TFPI is present within human atherosclerotic plaque and is associated with attenuated TF activity, and the tissue factor pathway also appears to have
a role in vascular proliferation and remodelling caused
by vascular disease.
To study the interplay between TF and TFPI and the
regulation of vascular thrombogenicity in vascular
remodelling, the author used a murine model of flow
cessation: carotid ligation. TF activity of the arteries
increased after ligation but TFPI expression did not
change compared with normal carotid arteries, and the
result was an enhanced TF activity.

PHLEBOLYMPHOLOGY 2002

Treating mice with adenoviral delivery of either
murine TFPI or a control adenovirus, the author found
that overexpression of TFPI decreased vascular TF
activity compared with viral control and inhibited
neointimal formation, resulting in increased luminal
area and in attenuation of vascular remodelling associated with flow interruption.
Interaction between TF and TFPI also takes place in the
bloodstream, and it may regulate progression of
thrombus propagation and thrombus formation.
Using irradiated mice and bone marrow transplant, the
author obtained animals where wall TFPI was normal,
while they had different circulating TFPI; it seems that
this form of TFPI deficiency accelerates thrombus propagation, but does not affect thrombus initiation.
Modulation of the tissue factor pathway may offer a
new chance for treatment of vascular disease.

S17

NEW TECHNIQUES AND NEW TECHNOLOGY
IN VENOUS DISEASE
Chairmen: J. BERGAN (USA), J. CORSON (USA)

High ligation and stripping is the gold standard for treating
varicose veins
J. CORSON (USA)

The author reviewed different surgical procedures
used in treating saphenous varicose veins, including
high saphenous ligation with and without stripping,
segmental saphenous stripping with stab avulsion,
high saphenous ligation with sclerotherapy, and high
ligation with stab avulsion. He presented conclusive
evidence of the superiority of high saphenous ligation
and stripping of the saphenous trunk to the region of
the knee, thereby reducing the incidence of nerve
injuries.

The answer to the question regarding the value of
saphenous sparing therapy in order to preserve possible grafts for arterial reconstruction was negative.
New forms of therapy, such as minimally invasive
endovenous procedures will have to be compared to
conventional stripping therapy in their short- and
long-term efficacy.

Initial results of polidocanol microfoam treatment
of saphenous incompetence
C. McCOLLUM, D. WRIGHT, P. COLERIDGE SMITH (UK)

R ecurrence of varicose veins even after optimal surgical therapy is a well-known problem, with a frequency of between 10% and 50% on long-term follow-up. Ultrasound-guided sclerotherapy has been
one of the alternatives to conventional surgery. In
recent years microfoam sclerosants have appeared, and
the first short-term results of this therapy were
reported by the author. One advantage of microfoam
in comparison to liquid sclerosants is a displacement of
blood by the foam, thereby effectively transporting the

S18

desired concentration of sclerosant to the varicose
vein. Another advantage is the enhanced visibility of
foams under ultrasound.
First results of a pilot study in 36 patients showed a
1-year success rate of 80% with a single treatment.
Should these results be reproduced in larger studies
with a longer follow-up, this method might be one of
the solutions to varicose veins due to the simplicity and
the repeatability of this method.

PHLEBOLYMPHOLOGY 2002

Ablation of superficial reflux with radiofrequency and laser
N. MORRISON (USA)

In

recent years, minimally invasive endovascular
procedures on varicose veins done under local anesthesia and on an outpatient basis have attracted a lot
of attention by the general public.

Fifty-three patients with bilateral varicose veins were
treated, one leg with the RF treatment, the other leg
by laser. Eighty percent of the patients were female,
and the mean age was 58 years.

This is a first comparative study of the two most
frequently used methods, the CLOSURE method by
radiofrequency application and the endovenous laser
treatment (EVLT).

Short-term follow-up data was presented, with up to
now only 10% completing the 1-year follow-up. At 6
to 9 months 85% to 90% of treatments were successful (Table I).

Radiofrequency
Success rate in %/(n of pt)

Laser
Success rate in %/(n of pt)

100 (45)

95 (43)

93 (46)

91 (46)

3-5 months

100 (41)

91 (44)

6-9 months

90 (30)

61 (31)

10-12 months

80 (10)

80 (10)

1 week
4-8 weeks

Table I. Success rates of radiofrequency therapy vs endovenous laser treatment.

Both methods were comparable in efficacy, EVLT was
faster, and the single-use probes less expensive, but
more painful and resulted in larger hematomas.

It was reported that 9 out of 10 patients preferred
radiofrequency ablation to the laser therapy.

NEW TECHNOLOGY, THORACIC OUTLET SYNDROME
Moderators: H. BJARNASON (USA) and U. FRANK (Germany)

Straub-Rotarex™-assisted recanalization
of thrombotic/embolic arterial occlusions: long-term results
U. FRANK, T. ZELLER, K. BÜRGELIN, P. FLÜGEL, B. HORN, U. SCHWARZWÄLDER, F-J. NEUMANN (Germany)

Rotarex is a new device for embolectomy, catheterguided, which rotates and at the same time aspirates
thrombus and neointima.
The authors used such a device for treating 67 patients,
in 36% of the cases for acute thromboembolic occlusion of a native artery, and in 11% for acute bypass
occlusion, mean occlusion length was 21 cm, and 6%
of the patients were in Fontaine stage II a, 62% in stage
II b, 23% in stage III, and 9% in stage IV.

PHLEBOLYMPHOLOGY 2002

While primary success rate was very high, over 90%,
results were unsatisfactory for crossover intervention,
and long-term results were poor for bypass occlusions,
long-term amputation was 6%, and complications
included 10% thrombus migration and 6 cases of
vessel perforation, which were treated with covered
stents.

S19

Straub-Rotarex™-assisted recanalization of in-stent occlusions
of femoropopliteal arteries: long-term results
U. FRANK, T. ZELLER, K. BÜRGELIN, P. FLÜGEL, B. HORN, U. SCHWARZWÄLDER, F-J. NEUMANN (Germany)

T

he same device was used to operate on occluded
stents, 40 femoral, 23 popliteal, and 4 iliac.
If a stent was present, there was no danger of perforation, while three perforations occurred in vessels

where stents had not been used; primary success rate
was 98%, much less for crossover interventions, but
the main problem here was the high rate of restenosis,
which the authors plan to treat with radiation therapy.

Percutaneous transluminal angioplasty using gadodiamide
as alternative contrast agent in patients with contraindications
to iodine-containing contrast agents
U. FRANK, T. ZELLER, K. BÜRGELIN, P. FLÜGEL, B. HORN, U. SCHWARZWÄLDER, F-J. NEUMANN, (Germany)

Iodine-containing contrast agents are contraindicated
in some patients, and few prophylactic techniques can
be used to overcome this problem, so the authors performed 25 digital subtraction angiographies (DSA) in
such patients, 18 peripheral and 7 renal, using 0.5
molar gadodiamide (Omniscan™) injected intra-arterially, and 23 percutaneous interventions.
All interventions but one succeeded, and the quality of

the peripheral DSA was good in all peripheral vessel
cases, and sufficient in all renal cases. There were no
severe side effects, no allergic reactions, and no
changes in mean serum creatinine.
Up to now there is no producer approval for gadolinium intrarterial administration, there are no studies on
long-term renal function, and it is much more expensive than the other contrast media.

Videoscopic methods used in sympathetic denervations
J. WRONSKI, T. ZUBILEWICZ, M. FELDO, J. J. KESIK, J. MICHALAK (Poland)

The use of Doppler ultrasound in the investigation of thoracic
outlet syndrome: normative data
P. G. BYRNE, P. A. COUGHLIN, M. J. WESTON, R. C. KESTER, P. J. KENT (United Kingdom)

In the thoracic outlet syndrome (TOS) the majority of
symptoms, more than 90%, are caused by nerve compression; however, ultrasound methods are widely
used to investigate any possible vascular component at
rest and in provocative positions.
As it is well known that a number of patients will be
positive at clinical testing for the appearance of arterial
bruits and disappearance of the pulse during activating
manoeuvres, the authors decided to study with color

S20

Doppler flow and Duplex scanning 25 normal subjects,
11 female, 14 males, to assess the incidence of pathological findings.
In this perfectly normal group 64% of the subjects had
a positive arterial duplex, four of them bilaterally, and
venous entrapment was detected in eight arms: the
authors conclude that positive ultrasound results in
symptomatic patients should be treated with caution.

PHLEBOLYMPHOLOGY 2002

Part 2

AORTIC ANEURYSMS

AORTIC ANEURYSMS I
ETIOLOGY, GENETICS, TREATMENT
Moderators: P. GLOVICZKI (USA), P. BALAS (Greece)
With the participation of : D. Tilson (USA), W. Pearce (USA), F. Lederle (USA),
K. Wayne Johnston (Canada), P. Kalman (Canada), C. Zarins (USA)

T

he etiology of abdominal aortic aneurysms (AAA) is
multifactorial. The four principal positive risk factors
for AAA are smoking, age, male sex, and family history. An interplay between genetic and exogenous
factors in AAA formation has been suspected in the
past decade. The hypothesis that AAA is an autoimmune disease (like rheumatoid arthritis) needs further investigation to determine the responsible susceptibility genes, process genes, and structural genes.
Will we have in the future a simple blood test to
predict aneurysm formation?
Once AAA formation has been diagnosed in a patient,
the first treatment is a reduction of the cardiovascular
risk profile. Prevention of growth with medical therapy has been suggested (eg, propanolol, doxycycline,
macrolides) but no significant benefit has yet been
shown.
The best management for small AAAs remains controversial. In the UK small aneurysm study and the
ADAM study, no survival rate advantage could be
shown for early surgery in patients with nontender
4.0 cm to 5.5 cm diameter AAAs in comparison with
patients who were followed with serial ultrasound scan
surveillance until the aneurysm enlarged to greater
than 5.5 cm or was considered to be symptomatic.
From a surgical point of view we have to consider the
individual patient according to a proper selection based
on the following factors: (1) aneurysm rupture risk (eg,
gender, diameter), (2) elective operative risk in rela-

S22

tion to the surgical volume, impact of surgical training,
and individual patient risk factors ( most important are
COPD, coronary ischemia, and impaired renal function), (3) life expectancy, (4) whether the patient will
adhere to a strict follow-up.
Once we decide to treat an aneurysm we have the
choice between the open surgical repair and the alternative, less invasive endovascular repair. It is commonly assumed that if the patient survives open surgical repair, the patient is no longer at risk of aneurysm
rupture or aneurysm-related death. Late follow-up
scans after standard open AAA repair in a cohort of
patients from the registry of the Canadian Aneurysm.
Study demonstrates a significant prevalence of late
abnormalities (aneurysm of the thoracic and visceral
parts of the aorta, aneurysm of the aortic cuff,
aneurysm of the proximal anastomosis, aneurysm of
the iliac artery). On the basis of this findings a routine
CT follow-up 5 years postoperatively is recommended.
In his keynote lecture, C. K. Zarins (USA) showed, in
a review of 417 patients undergoing elective infrarenal
aneurysm repair (243 open repairs and 174 endovascular repairs), a significantly lower risk of
aneurysm-related death in favor of endovascular
repairs. Randomized studies are necessary to evaluate
whether endovascular aneurysm repair in morphologically suitable patients becomes the gold standard in
the future.

PHLEBOLYMPHOLOGY 2002

AORTIC ANEURYSMS II
Moderators: A. OLDENBURG (USA), P. KALMAN (Canada)

What is the best technique to image abdominal aortic
aneurysms for open surgical repair, and what is the best
for endovascular stent-grafts?
M. FILLINGER (USA)

Vascular imaging has dramatically changed , primarily driven by endovascular aneurysm repair.
In general, imaging criteria are not as demanding for
open surgical repair of AAAs. Sophisticated new imaging techniques are nonetheless helpful in generating
more useful information for operative planning with
less invasive preoperative studies.
CT angiography and 3-dimensional reconstructions are
superior to the traditional pairing of conventional CT
and angiography in cases of open repair, even in complex thoracoabdominal aortic aneurysms. Preoperative
imaging for endovascular aneurysm repair (EVAR) is
even more demanding, computer-aided measurement,
planning and simulation software (CAMPS) in combi-

PHLEBOLYMPHOLOGY 2002

nation with CT angiography and 3-D reconstructions
can eliminate measurement errors.
Errors of even 2 mm in diameter or 5 mm in length can
make the difference between success or failure.
In the future, the following protocol could be adapted:
• CT angiography with 3-D reconstructions is the
modality of choice;
• MRA or CT with gadolinium in patients with renal
insufficiency, creatinine > 2.5;
• Adjunctive duplex scanning in selective cases;
• Angiography before interventions will be rare (eg,
coiling before EVAR to prevent endoleaks).

S23

AORTIC AND PERIPHERAL ANEURYSMS
Moderators: C. ZARINS (USA), D. TILSON (USA)

Abdominal aortic surgery through a minilaparotomy
T. KLOKOCOVNIK (Slovenia)

Abdominal aortic aneurysm surgery through a small
retroperitoneal incision
A.LEDERMAN (Brazil), E.T. AGUIAR, P. MATSUNAGA

What is the future for minimally invasive technology
for aortic surgery?
Y. DION (Canada)

For the last three decades open repair of aorto-iliac
diseases has been the gold standard, but evolution of
material, better preoperative care, and specialized vascular training have not significantly improved the
results. Other techniques need further investigation
and the interest of a broader surgical public to maintain a better patient outcome.
Most of us are already familiar with the endovascular
treatment of aortic pathology, and its advantages are
clear. Minimal- access abdominal aortic repair is still in
its experimental phase.
Here is a short overview:
• Transperitoneal minilaparotomy (T. Klokocovnik): a
periumbilical median incision of 8 to 10 cm makes
endoaneurysmography possible, an identical incision
of 6 to 8 cm was needed for placing an aortobifemoral
prothesis for aortoiliac stenotic or occlusive disease. A
Cosgrove flex clamp is used percutaneusly for clamping aorta, and no ports or retractors were used. The
incision needs no additional surgical training and is
performed with standard equipment and instruments.
• Left small retroperitoneal incision (A. Lederman et al):
a 10- to 15-cm retroperitoneal small abdominal incision,
oblique, on the left side, opening the external oblique
muscle in the direction of its fibers and cutting internally
the oblique and transverse muscles is enough to expose
the abdominal aorta from the renal pedicle to both iliac
bifurcations. Clamps were inserted through small incisions (1.5 cm) above and below the main incision.

S24

• Laparoscopic vascular surgery, total or hand-assisted
(Y. Dion): surgeons less experienced in laparoscopic
techniques best start by using a hand-assisted device
through a transperitoneal or retroperitoneal (less problems with retraction of intestine) approach; this allows
one to feel the structures and to perform the anastomoses through the minilaparotomy. So one progresses
to a totally laparoscopic approach. With the development of vascular laparoscopic instrumentation, vascular clamps which can be left inside the abdominal or
thoracic cavity make it technically comparable to open
repair. Anastomoses are made easier by the use of
robotic systems which have already been put to test.
Combining laparoscopy with endovascular techniques
for treatment of some type II endoleaks is already a
reality. Studies are also being conducted in order to
determine how laparoscopy could best be used in order
to treat or prevent the development of type I
endoleaks. In experienced hands this technique will
result in a better patient outcome. Advantages include
reduced risk of paralytic ileus, decreased postoperative
pain, and a good esthetic result with smaller incisions
and less secondary incisional hernias, dimished ICU
stay, and faster recovery with shorter hospital stay.
Organization of courses (teaching sessions, live
demonstrations, dry lab with pelvic trainer, animal lab)
and a minimally invasive vascular forum can only
improve the results.

PHLEBOLYMPHOLOGY 2002

Popliteal aneurysms: a 20-year experience
C. ZORZOLI, E. CALLINI, F. D’ANGELO, A. PASTORE, M. VAGHI, R. MATTASI (Italy)

In this study the author examined the experience of
the last 20 years according to symptoms at the time of
operation. One hundred and one patients were studied and divided into three groups: asymptomatic, acute
symptoms (ischemias, rupture) and chronic symptoms
(claudication, paresthesia, and edema).
In this series of patients 31% suffered from a bilateral
popliteal aneurysm and 24.7% suffered from an
aneurysm at another location.
Concerning the operative technique the following
recommendations were given by the author: preference for a posterior surgical approach (anatomical position of graft) preference for a saphenous vein (no
aneurysm formation of vein graft in this study!), and
in acute symptoms intra-arterial trombolysis improves
the distal runoff and outcome.

Primary patency and limb salvage were examined.
The comparison of the results between asymptomatic
patients and patients with acute ischemia showed that
data from the two groups were significantly different
(P<0.001). The comparison of the results between
asymptomatic patients and patients with chronic
symptoms shows a lower rate of significance (P=0.01).
In contrast to aortic aneurysms, in which the risk of
rupture is known and positively correlated with the
diameter, the popliteal aneurysms rarely rupture but
more often lead to thrombosis even in small
aneurysms. As very good results are shown in surgical
treatment of asymptomatic aneurysms, it is clearly
advisable to operate also on small aneurysms. This
strategy leads to a higher rate of limb salvage (limb
salvage in asymptomatic patients was 100% after 1.5
and 10 years!).

AORTIC ANEURYSMS AND DISSECTIONS:
OPEN OR ENDOVASCULAR REPAIR?
Moderator: F. VEITH (USA)

Keynote lecture: The natural history of thoracoabdominal aortic
aneurysms and the effectiveness of surgical treatment
H. SAFI (USA)

The

incidence of this entity is around 5.9/100
000/year and is associated with aortic dissection in
25% of cases. If left untreated it has a 5-year survival
rate in the range of 10% to 20%. The risk factors for
rupture are increasing aortic size, advanced age, elevated mean arterial blood pressure, and associated
chronic obstructive pulmonary disease.
Mortality rates for TAA repair range between 4% and
21% depending on the series. H. Safi presented his very
PHLEBOLYMPHOLOGY 2002

extensive experience with a series of 854 patients with
thoracoabdominal and descending aortic aneurysms,
with a mortality rate of 15%. He has pointed out the
crucial use of cerebrospinal fluid drainage and distal
aortic perfusion in order to diminish neurologic damage during surgery. Thus they have an early neurologic
deficit of 3.5% for non-type II TAA and descending
TAA and 7% for type II TAA.

S25

The use of 3D imaging and volume measurements
for endograft surveillance
H. BEEBE (USA)

E

ndovascular treatment of AAA has the objective of
durable protection from rupture. This fact has led us to
a strict surveillance program in order to detect failure
and, if possible, to predict which will be the failing
grafts (migration, kinking, or AAA expansion). In the
mid 1990s it was initially thought that two criteria
sufficed to demonstrate clinical success: absence of
endoleak and shrinking AAA size. However, this is not
completely true. Shrinking of the AAA may cause
migration in attachment zones, graft kinking leading

to occlusion, traction, and separation of modular
segments or angulation inducing fabric penetration by
metal stent components. Apart from these there can be
device fatigue fractures, attachment zone dilatation, or
new aneurysm formation. Fine collimation CT scans
with 3D postprocessing is presented as the imaging
method of choice, because it allows precise determination of morphology and provides volumetric calculations that have been proven to be the most sensitive
indicator of AAA exclusion.

Open or endovascular repair of abdominal aortic aneurysms?
Current practice at the Mayo Clinic
P. GLOVICZKI (USA)

B

etween 1980 and 2001 5352 aortic aneurysms were
repaired at the Mayo Clinic. The mortality rate for open
repair has been under 3% in the past two decades, but
morbidity is significant; 22% had cardiac or pulmonary
complications. The long-term graft patency following
open repair is excellent (97% at 10 years).
During 2001 260 AAAs were repaired, 80 using

endovascular repair which represents 31%. Currently
open repair is recommended at the Mayo Clinic to treat
AAA. EVAR is performed upon elderly and high-risk
patients with good results. The high reintervention
rate, the chance of late rupture, high graft cost,
decreased graft patency, and need for continuous
follow-up remain a concern.

Open or endovascular repair of type B aortic dissections?
Current practice at the Cleveland Clinic
R. GREENBERG (USA)

P

rofessor Greenberg has presented his experience
treating aortic dissections differentiating between
acute and chronic. When confronted with acute dissections the first step is to initiate medical care; when
a rupture or ischemic complications occur, surgical
treatment is the method of choice. This treatment can
be approached by means of endovascular and open

S26

repair. Chronic dissections demand strict imaging
follow-up. When there is degeneration of the wall,
rupture, or ischemic changes, a surgical approach is
mandatory.
The key future points are to identify the patients at risk,
to improve the endovascular devices to treat kinking
arteries, and to apply the best imaging diagnostic test.
PHLEBOLYMPHOLOGY 2002

Results of the US experience with the Gore Excluder
bifurcated endoprosthesis
T. SULLIVAN (USA)

A

fter presenting the Excluder prosthesis, T. Sullivan
presented the results of the US pivotal trial in 235
patients. The 1-year results show absence of endoleaks
in 84%, migration of the device in 2.7%, and no fractures. The AAA diameter diminished in 24%, did not
change in 73%, and increased in 3%.

The advantages of this EG are low profile, flexibility,
good proximal anchorage, and ease of use. The negative aspect is the anatomic limitations in large caliber
arteries.

Results of the US Pivotal trial of the Talent LPS Stent-graft
for repair of AAAs
F. CRIADO (USA)

T

he talent LPS Stent-graft is a modular, self-expanding graft that can be inserted in the suprarenal position
and is available in large sizes with ease of use. The
1-year results of the trial comparing 237 EAVR with

240 open repair, compare favorably with open repair.
The detection and analysis of ruptures of the graft have
permitted the production of the Enhance Talent LPS
which is now being submitted for an ongoing trial.

Long-term results with the EVT/Ancure Endograft System
for repair of AAAs
W. MOORE (USA)

The Ancure (Guidant) bifurcated graft system was
first implanted in 1994, and since then a total of 268
patients have undergone implantation as part of a
multi-institutional, prospective, non-randomized
control study in the management of patients with

PHLEBOLYMPHOLOGY 2002

AAA. After 4 years’ follow-up this system has proved
to be a durable procedure for the management of
anatomically suitable patients with 26% endoleak rate
(type II or indeterminate) at 36 months.

S27

AORTIC ANEURYSMS: ENDOVASCULAR REPAIR
Moderators: J. PARODI (Argentina ), C. ZARINS (USA)

Keynote address: The Montefiore experience
with endovascular repair of elective and ruptured
abdominal aortic aneurysms (AAA)
F. VEITH (USA)

During the last 11 years 475 cases were successfully
treated by transluminally placed endovascular grafts
(TPEGs), although 34 patients have had early or late
endoleaks.
Advantages and disandvantages of the various devices
were as follows:
• The EVT Ancure graft is more complicated to insert
but is relatively free of late problems.
• The Talent device is versatile, accommodating
aneurysms with large-diameter infrarenal necks and
iliac arteries. However, it has a relatively large diameter and less flexible introducer systems.
• The Gore Excluder and Cook Zenith devices have
highly flexible, small-diameter sheath-introducer systems. The Cook Zenith device is quite versatile and has
secure suprarenal fixation.
• The Montefiore Endovascular Grafting System
(MEGS), consists of an aortounifemoral PTFE graft

fixed proximally with a Palmaz stent and distally with
a sutured endovascular anastomosis, combined with a
femoro-femoral graft, a contralateral common iliac
occluder, and ipsilateral hypogastric coils. The MEGS
device is versatile, can be prepared in 2 sizes which fit
most patients, can conform to 600-900 neck angulation,and has suprarenal fixation. It has a relatively
small, flexible introducer system.It is effective for the
treatment of ruptured AAAs. However, it requires supplemental stent placement.
Since 1993, the department had treated 31 ruptured
aortoiliac aneurysms endovascularly (25 with endografts) and had only a 10% mortality rate.
In conclusion, the availability of a variety of TPEGs
with different assets and limitations facilitates and
improves the endovascular treatment of aortoiliac
aneurysms. Optimal device utilization must be
achieved by matching the device used to aneurysm and
arterial morphology.

Is percutaneous endograft placement possible, and what
is the benefit of intravascular ultrasound?
R.WHITE (USA)

During his talk R. White described the Endologix unibody bifurcated endograft which requires surgical exposure of only one vessel and has the unique advantages of percutaneous delivery of the contralateral limb.
He also recommend the use of intravascular ultrasound (IVUS) which provides data that is otherwise not

S28

available by conventional imaging modalities, such as
the cross-sectional area of the vessel lumen and
vascular wall prior to and following procedures. An
additional benefit of IVUS is that cinefluoroscopy time
and contrast utilization can be significantly reduced,
minimizing the risks to the patient and personnel.

PHLEBOLYMPHOLOGY 2002

Lessons learned from the EUROSTAR registry on endovascular
repair of abdominal aortic aneurysms
J. BUTH (The Netherlands)

The results of over 4000 patients from 110 European
institutions were collected and analyzed. Preoperative
data regarding endoleaks were compared for patients
with collateral retrograde perfusion (type II) endoleak,
with device-related (type I and type III) endoleaks and
patients in whom no endoleak was detected. Only
those endoleaks observed after the first postoperative
month of follow-up were taken into consideration.

The analyses showed that the presence of devicerelated endoleaks correlated with a higher risk of
aneurysmal rupture and conversion compared to
patients without type I and type III endoleaks. Type II
endoleak was not associated more often with these
events. Consequently intervention in type II endoleaks
should only be performed in case of increase of
aneurysm size.

Long-term results of endovascular treatment of abdominal
aortic aneurysms: the Cleveland clinic experience
K. OURIEL (USA)

The main points of K. Ouriel’s talk referred to the failure modes of aortic endoprostheses which depend on:
• the characteristics of arterial anatomy;

It is precisely these interactions that determine
whether or not a patient is protected from aneurysm
rupture over long-term follow-up.

• the device itself;
• the interplay between anatomic changes and device
conformability to such changes.

PHLEBOLYMPHOLOGY 2002

S29

Part 3

ATHEROSCLEROSIS

RISK FACTORS OF ATHEROSCLEROSIS
Moderators: H. RIEGER (Germany) and T. ROOKE (USA): F. VEITH (USA)

Keynote Lecture: Global cardiovascular risk in patients
with peripheral arterial diseases
S. NOVO (Italy)

T

he concept of arteriosclerosis of the lower extremities as a marker of risk for total cardiovascular morbidity and mortality is well established. Numerous
studies like the Whitehall study, the San Diego study,
and others, have shown that if one follows prospectively a group of patients with peripheral arterial
disease (PAD) and compares them with healthy
controls, morbidity and mortality is increased in the
PAD group by a factor of 2. S.W. Cheng et al analyzed
the survival of 655 patients with PAD in a follow-up of

5 years, and reported a cumulative survival of 86.1%,
71.2% and 55.8% at 1, 3, and 5 years.
S. Novo recommended treating these patients in a very
intensive manner, like coronary patients, with an
aggressive control of risk factors, following the different recommendations listed in the report of the Task
force1 on management of peripheral arterial diseases.
Reference
1. Samain E, Farah E, Lesèche G, Marty J. J Vasc Surg. 2000;31:971-979.

What techniques have been effective at the Mayo clinic
to stop smoking?
R. HURT (USA)

Optimizing adherence to smoke cessation in vascular disease
patients: is this possible? The Canadian perspective
J. IRVINE (Canada)

T

ailoring the techniques of counseling and pharmacotherapy to the needs of the individual patient using
serum concentrations of cotinine (a major metabolite
of nicotine) can increase smoking cessation rates, as
was pointed out by R. Hurt. He presented the experience at the Mayo Nicotine Dependence Center in USA.
This group uses the serum levels of cotinine to adjust
the dosage for nicotine patches on an individual basis
in order to control the abstinence syndrome. In heavy
smokers, more intensive treatment is obtained on the
basis of inpatient-hospitalized programs with a
reported long-term abstinence rate of 50%.

S32

The group of J. Irvine in Canada did a prospective study
with 337 patients with PAD. The purpose of the study
was to analyze the smoking cessation rates using two
different types of behavioral interventions, one based
on social cognitive theory and the other on the transtheoretical model. Both behavioral interventions were
associated with a very low cessation rate (9% to 12%)
at 1 year. Living alone, problem drinking, and lower
self-confidence for cessation appear to be associated
with greater resistance to smoking cessation programming.

PHLEBOLYMPHOLOGY 2002

Part 4

CEREBROVASCULAR
DISEASES

CEREBROVASCULAR DISEASE I
Chairman: K. CHERRY (USA), G.DERIU (Italy)

Conventional endarterectomy of the carotid arteries is a safe,
effective, and durable procedure
G. DERIU (Italy)

The incidence of carotid artery disease: lessons learned from
the Cyprus carotid study
N. ANGELIDES (Cyprus)

Even though carotid endarterectomy is a safe, effective, and durable procedure, the number of carotid
operations performed is smaller than required. In order
to improve this situation, the authors suggest increasing the number of centers undertaking carotid
endarterectomy, and improving patient awareness
(improved carotid registry). They performed 4 pilot
studies in:

Patients with severe (>70%)
carotid stenosis

1. 100 asymptomatic persons.
2. 100 symptomatic patients with a stroke.
3. 100 symptomatic patients with TIAs.
4. 100 asymptomatic patients with carotid bruit.
The patients were examined with color duplex scan.
The authors observed a greater number of patients with
severe carotid stenosis in symptomatic (with TIAs and
with a stroke) than in asymptomatic persons (Table I).

Asymptomatic
persons

Symptomatic
with TIAs

Symptomatic
with stroke

3%

25%

36%

Table I. Results of the Cyprus carotid study.

In asymptomatic patients with carotid bruit they observed a greater percentage of persons with moderate carotid
stenosis than in asymptomatic persons.

S34

PHLEBOLYMPHOLOGY 2002

Intraoperative hemodynamic assessment following carotid
endarterectomy experience with a new, angle-independent
Doppler
T. E. RASMUSSEN, J. M. PANNETON, M. KALRA, J. M. HOFER, B. L. LEWIS, T. C. BOWER, K. J. CHERRY,
A. A.NOEL, P. GLOVICZKI (USA)

T

o assess hemodynamic adequacy of carotid
endarterectomy intraoperatively the authors applied a
new, angle-independent Doppler device. By using dual
beam with a diffraction process, the EchoFlow
provided Doppler velocity assessment independently
of the insonation angle. In their paper they compared
velocity measurements of the common(CCA), internal(ICA) and external(ECA) carotid arteries obtained

in standard Duplex ultrasound and in the EchoFlow.
Seventy-five percent of CCA, 88% of ICA, and 78% of
ECA velocity measurements obtained with inexpensive, angle-independent Doppler device were within
25 cm/sec of the velocities measured by duplex ultrasound. They concluded that the data are reproducible
and comparable to those obtained with duplex ultrasound.

Keynote Lecture: The state of the art of carotid stenting
R. HOBSON (USA)

Endoluminal surgical treatment of common carotid
artery disease
J. F. CORMIER, F. CORMIER, J. M. FICHELLE (France)

C arotid angioplasty-stenting has been recommended
by some clinicians as an alternative to carotid
endarterectomy especially in:
1. carotid restenosis.
2. high-risk patients.
3. anatomical lesions.
4. radiation-induced stenosis.
Although the total number of major strokes after
endovascular treatment is still greater than after
carotid endarterectomy, some authors obtained very
good results in the maintenance of primary patency of
carotid artery after endovascular procedures. Prof
Cormier presented data on 39 patients who underwent

PHLEBOLYMPHOLOGY 2002

43 angioplasty-stenting procedures in the common
carotid arteries (CCA) and innominate artery (IA). For
cerebral protection CCA clamping was used. One
patient died following common carotid artery stenting
due to hemorrhagic stroke. There were 2 anatomical
complications: one false IA aneurysm and one dissection followed by restenosis. Both were treated by a
stent procedure. The primary patency was 77% with
7 restenoses in 3 years’ follow-up.
The authors presented the opinion that despite
advanced medical techniques, carotid angioplastystenting should be limited to well-controlled randomized studies.

S35

CEREBROVASCULAR DISEASE II, MEDICAL, SURGICAL,
AND ENDOVASCULAR TREATMENT
Chairmen: A. NICOLAIDES (Cyprus), W. BAKER (USA)

Conventional carotid endarterectomy and venous patch
angioplasty: the gold standard
E. A. BASTOUNIS (Greece)

Conventional endarterectomy with bovine pericardium patch:
a comparison with polyester patch angioplasty
A. OLDENBURG (USA)

To avoid perioperative stroke, and thrombosis or
restenosis of carotid arteries patch angioplasty was
used by the authors in the presented papers. The patch
can be constructed from the saphenous vein, polyester,
ePTFE, or bovine pericardium. In the first paper the
author analyzed 423 carotid endarterectomies in 337
patients, all carried out with venous patch angioplasty.
There were no strokes in the perioperative period, and
the mortality was 0.47%.

A. Oldenburg, in the preliminary report, presented a
comparison of Dacron patch angioplasty vs bovine
pericardial patching in the group of 125 patients who
underwent carotid operation. Bovine pericardium was
used in 42% cases, and Dacron patch in 58% cases.
There were no postoperative strokes in either group,
and the combined 30-day mortality rate for both
groups was 0.7%.
Table II presents the collected data.
Polyester

Bovine

Revision

3.8%

0

Late mortality

4.2%

0

0

0

1.9%

1.4%

7%

0

2.5%

2%

30-day neurological deficit
Late neurological deficit
Reccurent stenosis
Reoperation

Table II. Carotid endarterectomy with bovine pericardium vs Dacron.
The authors concluded that bovine pericardium in terms of safety is comparable to Dacron patching.

S36

PHLEBOLYMPHOLOGY 2002

Eversion carotid endarterectomy gives the best long-term
surgical results
D. SHAH (USA)

According to the authors, the eversion endarterectomy technique allows for complete removal of atheromatous plaque and examination of distal and proximal
arteries, to decrease the restenosis and occlusion rate.
The authors performed carotid operations by means of

an eversion technique in 4000 patients. The mortality
rate was 1.2%, and the early occlusion rate 0.7%. The
authors stated that shunting during this type of operation is as easy as during a standard endarterectomy.

Keynote Lecture: Asymptomatic carotid lesions are markers
of future cerebrovascular and cardiovascular events:
what should we do?
S. NOVO (Italy)

S everal

studies have shown a close correlation
between asymptomatic plaques of the peripheral and
carotid arteries as well as between many risk factors
such as hypertension, smoking, hypercholesterolemia
and intima-media thickening.
In asymptomatic patients with carotid stenosis greater
than 75%, the risk of a stroke is 2.5% and with occlu-

PHLEBOLYMPHOLOGY 2002

sion the risk increases to 20% to 30%. On the other
hand the asymptomatic carotid lesion seems to be an
important risk factor for cardiovascular morbidity and
mortality. The first thing to be done is treatment of the
risk factors by reducing hypercholesterolemia and
hypertension. Antiplatelet drugs may also be very
useful in reducing vascular events.

S37

CEREBROVASCULAR DISEASE III
Moderators: W. MOORE (USA), G. BIASI (Italy)

Ultrasonic texture analysis and symptoms
A. NICOLAIDES (Cyprus)

Carotid plaque at risk for ischemic cerebrovascular events
A.VISONA, G. CARRA, L. LUSIANI, R. PESAVENTO, D. TONELLO, C. BULLO, A. PAGNAN (Italy)

The relationship between carotid plaque morphology
and cerebrovascular events is a fact, and any method
that can better differentiate between a vulnerable
plaque and a stable plaque is worthwhile. The histological characteristics of an unstable plaque are as
follows (1993): (a) thin fibrous cap, (b) lipid-rich core,
(c) macrophage-rich, (d) poor smooth muscle content.
As far we know lesions at risk for new events have a
non-homogenous appearance with an irregular surface on duplex echography. The degree of stenosis and
progression are also important.
A new method has been developed by the team of A.
Nicolaides, providing reproducible measurements of
plaque echodensity. Images are digitalized and normalized on a PC using linear scaling with two reference
points: blood (gray scale=0) and adventitia (gray
scale=190). After image normalization the gray scale
median value (GSM) of the pixels of the plaque is
obtained.
A group of 100 patients was investigated according to
the degree of stenosis, hemispheric symptoms, and the
plaque GSM.
Three important groups could be distinguished:
• Patients who present with transient monocular blindness have plaques with GSM <10 (black) and
stenosis greater than 90%. It has been suggested that
these plaques are of uniform consistency, and the
stresses within them during pulsation are minimal.

S38

They tend to grow without rupture and produce tight
stenoses (>90%). Tight stenoses produce a fine jet of
blood with platelet aggregates forming on the low
shear stress regions of the arterial wall in the poststenotic dilatation area breaking off and sending showers of platelet emboli to the brain. The showers of
platelet emboli are not detected by the brain but are
detected by the retina.
• Patients who present with TIAs and strokes
have echolucent plaques with some echogenic areas
with a GSM of 10 to 25 and a stenosis of 70% to 85%.
These plaques have a non–uniform consistency and
the high stresses within them during pulsation tend to
produce rupture before they become severely stenotic
and produce TIAs and strokes.
• Asymptomatic patients have plaques with
GSM >30. These plaques have a high content of fibrous
tissue and tend to be asymptomatic irrespective of the
degree of stenosis.
The ultrasonographic assessment of the grey scale
median of the carotid plaque is an easy, inexpensive,
reliable, and quantifiable method to identify the
plaques at risk in patients who need immediate investigation and treatment. These data could even provide
a valuable contribution to the criteria for selection of
patient candidates for carotid stenting or carotid
endarterectomy, and should be used in natural history
studies.

PHLEBOLYMPHOLOGY 2002

Why is conventional carotid endarterectomy the best treatment
for carotid artery disease?
T. RILES (USA)

Why is surgical treatment superior to carotid stenting?
J. FERNANDES E FERNANDES (Portugal)

The current state and future prospects of carotid stenting
J. PARODI (Argentina)

New technology must:
1. Improve patient safety
A carotid plaque has a friable surface pathology (calcifications, thrombus, ulcerations) with a high risk of
embolisation. Every passage through a carotid lesion
with guidewires, catheters, distal occlusive balloons,
and filtration protective devices can cause a cerebrovascular event.
Several studies1,2 show a better outcome regarding
combined stroke/death rate in favor of carotid
endarterectomy.
Cerebral protection devices are in the progress of being
considered standard practice during stenting, taking
care of acute particulate embolization during the procedure and resulting in increased success rates. Preliminary results with a new protective device engineerd by Parodi (occlusion of inflow with a proximal
ballon and create reversal flow in the ICA, so without
passing the ICA lesion) are promising. A drawback of
carotid stenting at this time, even in the hands of skilled
operators, is restenosis (7%).
On the other hand, early recurrent carotid stenosis
after carotidendareterectomy shows good results with
carotid stenting.

2. Reduce patient discomfort
The esthetic outcome (scar) after carotid endarterectomy is less important in an older group of patients:
they prefer a result without a cerebrovascular event.
The controversy regarding surgery or stenting in the
carotid territory is somewhat different from in the
coronary territory; the former being easy to access
under local anesthesia, the argument of reduced invasiveness becomes less relevant than with the latter.

PHLEBOLYMPHOLOGY 2002

3. Provide treatment for a new population
Regarding age as part of the risk profile, a study of outcome in patients younger and older than 80 years
treated with carotid stenting resulted in a stroke death
rate of 6.6% against 19%. There is, however, a group
of patients who benefit from carotid stenting: hostile
necks (radical neck dissection, stomas, radiotherapy,
giant hemangiomas), high lesions (above C2) and low
lesions in the thorax, early recurrent restenosis, and
dysfunctional contralateral cranial nerves.

4. Diminishing costs, hospitalization,
recovery time
There are no studies available.
In summary, carotid endarterectomy remains the gold
standard. Reduction of the surgical risk (eg, completion assessment with intraoperative duplex) provides
excellent results in skilled hands.
Nevertheless, a positive evolution of endovascular
materials (eg, protective devices with reversal flow
technique, low-profile monorail systems) may
improve on the results. J. Parodi believes that between
5% and 10% of the patients referred for carotid
endarterectomy will be better served by carotid stenting in first-class medical environments. It is recommended that despite continuing advances in techniques, carotid angioplasty and stenting must be
limited to well-controlled randomized studies.

References
1. Wholey M.H, Wholey M, Mathias K et al. Catheter Cardiovasc Interv.
2000;50:160-167.
2. Roubin GS, New G, Iyer SS, et al. Circulation. 2001;103:532-537.

S39

Part 5

CHRONIC VENOUS DISEASE

NEW DEVELOPMENTS IN THE MANAGEMENT
OF CHRONIC VENOUS DISEASE
Chairmen: H. PARTSCH (Austria), M. PERRIN (France)

The role of elastic compression stockings in the treatment
of chronic venous disease
H. PARTSCH (Austria)

The conventional concept of compression therapy
consists of two phases: 1) therapy or decongestion
phase; 2) maintenance phase. Multilayer compression
bandages are preferred for the first phase and compression stockings for the second.
Compression has different effects on CVI:
• edema reduction;
• effects on microcirculation (acceleration of the blood
flow in capillaries, improvement of lymph drainage,
pain relief);
• effects on macrocirculation (decrease in vein diameter, increase in flow, decrease in reflux, decrease in
venous hypertension, improvement in venous pumping, prevention of postthrombotic syndrome, ulcer
healing).
Recommendations were given at a meeting in Paris
recently, according to the results and the quality of the
different trials (Table I).

Class II stockings improve venous pumping. Belowknee stockings are preferable as they are usually
tolerated, as skin changes never occurred above the
knee. The indications for class II stockings are maintenance therapy in CVI.
Class III and IV stockings are more active on the deep
venous system than class II stockings, and reduce leg
volume more in CVI swelling and lymphedema. One
recent study showed that narrowing the femoral vein
seems to be more effective with adhesive bandages
than with class III stockings. Adhesive bandages reduce
edema by 54% and reflux by 65% versus 30% and
43% for class III stockings.
Concerning prevention of postthrombotic syndrome,
controversial results have been published.1-3 More
trials are needed to confirm or not whether compression therapy can prevent postthrombotic syndrome.

Class I

Class II

Class III

Class IV

C0-C1, S

+

C2 after surgery or sclerotherapy

++

++

C3

++

++

(+)

C4

+

++

++

C5

+

+

(+)

C6

+

+

(+)

(+) no data ; + data grade C, ++ data grade B.

Table I. Recommendations for stockings (Paris, January 2002).
References
1. Brandjes PM, Buller HR, Heijboer H, et al. Lancet. 1997;349:759-762.
2. Ginsberg JS, Hirsh J, Julian J, et al. Arch Intern Med. 2001;161:2105-2119.
3. Cullum N. Cochrane Library. Issue 4, 2001 Oxford: Update Software.

S42

PHLEBOLYMPHOLOGY 2002

The effectiveness of compression treatment with bandaging
in the treatment of severe chronic venous insufficiency
K. BURNAND (UK)

T

he speaker reported one randomized study (which
is to be published), comparing 4-layer Charing Cross
bandages with 3-layer paste semirigid bandages. One
hundred and thirty three patients were analyzable.
Compression was applied for 52 weeks. Healing rate
and time to heal (12 versus 16 weeks) were signifi-

cantly better in the 3-layer bandages group than in the
4-layer bandages group. The major difference occurs
after 16 to 20 weeks, mostly in the recalcitrant ulcer
subgroup which healed better and faster with the
3-layer paste bandages. Cost benefit and application
time also favored the 3-layer bandages.

New technology for local treatment of venous ulcers
G. MONETA (USA)

Tissue engineering is currently developing for the

USA for local treatment of diabetic wounds and venous
ulcers. The Apligraf® is an expensive device, but gives
especially good results in terms of complete healing
rate and time to heal (1) for recalcitrant ulcers (long
duration and large size). An algorithm for therapeutic
decision was proposed, according to the results of trials with Apligraf® (Figure 1).

local treatment of venous ulcers. Products combine living cells with extracellular support components.
Apligraf® is a bilayered skin construct, made of neonatal foreskin cells (fibroblasts and keratinocytes) in a collagen bovine matrix. It handles like human skin and is
easy graftable. Apligraf® was approved by the FDA in

Venous ulcer 

Conventional treatment: debridement ,
control of infection and edema, compression 

Healing process for 4 weeks  

Poor healing  

Apligraf®, 1 application 

Maintenance
of conventional treatment  

Good healing

Bad healing 

Re-application of Apligraf®
(no more than 3 times) 

Bad healing 

Further reading
Falanga V. Arch Dermatol. 1998;134:293-300.

PHLEBOLYMPHOLOGY 2002

Flap
Venous surgery
Ulcer excision

S43

Current surgical treatment of varicose veins and saphenous
incompetence
H. SCHANZER (USA)

Endovenous treatment of superficial incompetence
J. BERGAN (USA)

S ince the 1990s, less invasive surgery has been performed to treat superficial venous incompetence such
as proximal stripping-stab avulsion of the greater saphenous
vein. This technique avoids saphenous nerve injury and
allows a partial preservation of the saphenous vein for
further bypass surgery if necessary. Recurrence rate
with this technique fluctuates between 2% and 10%
after 3 years’ follow-up.
Endoluminal ablation of the saphenous vein is now
currently performed, either by laser (Diomed™,
Endolaser 810 nm) or by radiofrequency thermal
injury (VNUS Closure System™). Thermal injury by
VNUS Closure system has its advantages (local anesthesia, excellent immediate cosmetic results) and disadvantages (very expensive, complicated logistically,
predisposal to late groin recurrence in the absence of

high ligation). Most patients (77/85) resumed all
preoperative activities in less than 24 hours. The rate
of occlusion is around 92% after 2 years’ follow-up and
the rate of nonreflux recurrence is 93%. The risk of
skin burn is higher than with stripping (1.9 versus 0%)
but the risk of infection and paresthesia is much lower.
Endolaser Diomed™ appears to be faster and cheaper
than the VNUS Closure system, and perhaps better in
terms of long-term ablation of the reflux (100% no
reflux after a follow-up between 2 and 12 months) but
it is more painful.
Liposuction-avulsion of varicose veins is a newly developed
technique, called the TriVex™ system. This is a transilluminated powered phlebectomy, avoiding multiple
incisions to remove fragmented veins.

Evidence for effectiveness of deep vein valve reconstruction
M. PERRIN (France)

T

he effectiveness of deep vein valve reconstruction
remains debatable in the absence of prospective randomized studies, but many series results have been
reported in the last 20 years. Indications for deep vein
reconstruction rely on:
• clinical severity after failure of conservative treatment
• and imaging assessments. Reflux has to be severe,
with a refill time <12 sec and a delta pressure <40%.
In cases of primary deep venous reflux, reconstructive
deep venous surgery can be recommended in young
patients with recurrent venous ulcers. Good clinical

S44

results are expected in 70% of cases (5 years of followup) after deep venous reflux surgery, mainly valvuloplasty. The recommended technique is valvuloplasty
reconstruction.
In cases of secondary deep venous reflux, SEPS is
recommended as an associated procedure. The procedures of choice in cases of secondary venous reflux are:
transposition > transplantation > cryopreserve transplants. Good clinical results are expected in 50% of the
cases, without any correlation between clinical and
hemodynamic results.

PHLEBOLYMPHOLOGY 2002

Surgical reconstruction for iliofemoral and inferior vena
caval occlusions
P. GLOVICZKI (USA)

Open

surgical venous reconstructions are rarely
performed.1 De Palma procedures (femoro-femoral
saphenous vein graft) have a better rate of patency
after 2-year follow-up than prosthetic reconstructions
(83% versus 54%), when occlusion was due to a nonmalignant disease. Inferior vena caval reconstruction

after treatment for malignancy also gives a good rate
of long-term patency, but follow-up is difficult because
of the nature of the disease.
Reference
1. Jost CJ, Gloviczki P, Cherry KJ Jr, et al. J Vasc Surg. 2001;33:320-328.

CHRONIC VENOUS DISEASE
Moderators: S. SIMONIAN (USA), J. P. FLETCHER (Austria)

Bonn Vein-Study, epidemiologic study on the prevalence
and risk factors of chronic venous diseases
E. RABE, F. PANNIER-FISCHER, C. PONCAR, M. WITTENHORST, K. H. JÖCKEL (Germany)

The authors presented their newest epidemiological

• C0

9.5%

data on the prevalence of CVI in Germany. The last
previous study on this topic was the Tübingen Study
in 1979.

• C1

59.1%

• C2

14.2%

• C3

13.4%

The author’s study was begun in October 2000, and
3072 probands were entered up to March 2002. The
study population consisted of 1927 people from the city
of Bonn, and 1145 participants from rural townships.
43.9% were male, 56.1% were female, and the age
range was 18 to 79 years.

• C4

2.9%

• C5

0.7%

• C6

0.1%

All probands answered a standardized questionnaire,
and were examined by clinical means and by duplex
ultrasound. They were classified according to the clinical status of the CEAP classification.
Fifty-seven percent of probands suffered from leg
complaints, 30% complained of edema, and 28.9% of
varicose veins.
Clinical examination according to the CEAP classification showed:

PHLEBOLYMPHOLOGY 2002

Duplex examination demonstrated reflux in 28% of
the cases. In 72% no venous origin of leg complaints
could be found.
An interesting finding was the reduction in the prevalence of C4, and C5,6 when compared with the Tübingen study. In 1979 10.1% were in classified as C4, and
in 2002 only 2.9% were judged in that category. In
stages C5 and C6 the reduction was 2.7% to 0.8%.
Reporters’ note: This improvement in overall “venous health”
in the last 20 years can only be explained by better and earlier
treatment in patients with CVI.

S45

Patterns of venous reflux in patients presenting
with varicose veins
J. P. FLETCHER, P. JIANG (Australia)

A review was presented on patients with varicose
veins at a specialized vascular service over a 18-month
period. A total of 238 limbs in 152 patients were examined. The etiology was primary in 155 limbs (65.1%),
recurrent in 69 (29.0%), and secondary in 14 (5.9%).
While saphenofemoral incompetence was most
frequently found in primary varicose veins, saphenopopliteal incompetence was more commonly asso-

ciated with recurrent and secondary varicose veins.
Perforator incompetence was most frequent in the
cases of recurrence. There was an interesting increase
of the frequency of deep vein incompetence in patients
with recurrent varicose veins in comparison with primary varicosities for which no sufficient explanation
could be given (Table II).

Saphenofemoral
junction

Saphenopopliteal
junction

Perforator
incompetence

Deep vein
incompetence

Primary

62.3%

10.3%

47.1%

19.4%

Recurrence

43.5%

18.8%

63.8%

29.0%

Secondary

42.9%

21.4%

35.7%

50.0%

Table II. Frequency of reflux by Duplex.

Linear morphea after surgery of the saphenous veins
C. PONCA, F. PANNIER-FISCHER, M. WITTENHORST, R. GERDSEN, E. RABE (Germany)

An interesting case of a 64-year-old female patient
was presented, who developed a massive onset of linear morphea (a form of localized scleroderma) on both
legs after a bilateral crossectomy and stripping operation. The lesions started at the groin and progressed on
both medial aspects of the thighs corresponding to the
stripping channel. She also developed morphea on
both calves in the area of saphenopopliteal varicosities
which were not operated on.

S46

There are reports in the literature of a Koebner phenomenon (lesions developing in areas of unspecific
trauma) in morphea.
All the lesions so far have been resistant to different
forms of therapy including local steroids, general
antibiotics, and puva therapy which have been shown
to be effective in many of these cases.

PHLEBOLYMPHOLOGY 2002

CHRONIC VENOUS DISEASE AND VENOUS ULCERS
Chairmen: G. MONETA (USA), T. ROOKE (USA)

Conservative versus SEPS treatment of venous stasis ulcers
D. KRIEVINS, S. KOVALOVS, E. LIETUVIETIS, S. THOR, A. LACIS, G. MEDN, V. ALEKSANDROVICS (Latvia)

S

ubfascial endoscopic perforator surgery (SEPS) is a
minimally invasive method of treating perforator vein
incompetence. It is still difficult to assess the clinical
efficacy of isolated SEPS because it is frequently combined, in studies, with ablation of superficial reflux.
Nevertheless, randomized studies are needed to show
if SEPS combined with saphenous surgery is superior
to saphenous surgery alone in adjuvant treatment of
venous ulcers.
In this nonrandomized study, conservative treatment
(ie, compression) was compared with SEPS, in patients
with venous leg ulcers. SEPS was performed in 131
patients. Ablation of superficial reflux was performed

at the same time; if the patient was not operated on
prior to the study. Conservative treatment was prescribed in 44 other patients as four layers or short
stretched bandages. The two groups were not statistically different for current data and leg ulcer duration.
Median follow-up was 32 months in the surgical group
and 27 months in the conservative group. Complete
healing of the ulcer occured in 96% of the patients,
over a mean time of 7 weeks, versus 71% and 14 weeks
in the conservative group. These differences were
statistically significant. Recurrence rate during the
following period was significantly higher in the
conservative group: 27.3% versus 8.4%.

Healing process of venous ulcers: involvement
of microcirculation
M. E. GSCHWANDTNER, E. AMBROZY, G. HEINZ, S. MARIC, A. WILLFORT, B. SCHNEIDER, K. BÖHLER,
U. GAGGL, H. EHRINGER (Austria)

N

utritive flow of the skin is located superficially, in
the papillary dermis. It represents 15% of the total skin
flux and can be assessed by capillaroscopy (number of
capillaries/mm). Thermoregulation flow is located in
the medium and deep dermis. It represents 85% of the
total flux and can be assessed by laser Doppler (quantification of subpapillary flux by units of color). Using
these two methods, the authors described the modification of the microcirculation during the wound heal-

PHLEBOLYMPHOLOGY 2002

ing process. At the early stage of the ulceration, before
development of granulation tissue, laser Doppler area
flux and capillary densities were low. During granulation, laser Doppler area flux and capillary densities
increased significantly. When the ulceration was completely healed, laser Doppler flux on the scar was
significantly decreased to the level of the early stage.
In contrast, capillary density level was significantly
higher than before and during the granulation tissue.

S47

The use of cellulose membrane in the treatment
of venous leg ulcers
M. KUCHARZEWSKI, L. SULKOWSKI, A. SLEZAK (Poland)

T

his prospective study compared two topical
treatments in venous leg ulcers. Forty patients were
randomized. No significant difference was noted
between the 2 groups for usual data. Ulcers were either
treated with cellulose membrane (Bioprocess™) every
7 days or with enzymatic ointment once a day. All the
patients in the cellulose membrane group completely

healed in 10 weeks, versus 16 weeks in the other group
(P<0.005). Explanations for the efficacy of the
cellulose membrane was not clear. Occlusion, which
has been shown to promote wound healing, may be
provided by the cellulose membrane in contrast to
enzymatic ointment.

VASCULAR MALFORMATIONS
AND CHRONIC VENOUS DISEASE
Moderators: B. B. LEE (Korea), K. BURNAND (UK)

Prevention of neoangiogenesis after crossectomy
by implanting a Goretex plastic tube: 18-month results
K. SELZLE, S. SCHATTENKIRCHNER, I.KAMIONEK, M. SCHONATH (Germany)

The

purpose of this study was to prevent the
recurrence of reflux at the saphenous femoral junction
(and neoangiogenesis) with the implantation, after
crossectomy, of a Goretex tube. A prospective randomized controlled trial was conducted where the
stump of the long saphenous vein was closed after
crossectomy and saphenectomy with 3-0 Vicryl vasoligation (control group, 50 patients) versus covering of
the stump with a Goretex plastic tube (diameter:

S48

6-8 mm; length 5 to 10 mm) (50 patients study
group).Each patient was examined by color duplex
scan at 6, 12, and 24 months. They had 3.7% recurrences in the control group and 1.4% recurrences in
the treatment group at 24 months. They concluded
that despite a meticulously performed crossectomy,
recurrence of varices of the saphenofemoral junction
can occur. The study is continuing.

PHLEBOLYMPHOLOGY 2002

The laparoscopic diagnosis of pelvic varicose veins
M. L. PAVKOV, J. BROKELMANN (Germany)

T

he purpose of this study was to demonstrate the
importance of the laparoscopical diagnosis in the pelvic
congestion syndromes. A total of 2585 diagnostic
laparoscopies were performed for various reasons. The
authors gave importance to the positioning test that
consists in creating a pneumoperitoneum and
installing the patient in the Trendelenburg position to
see if the varicose pelvic veins are visible. If the presence of pelvic varicose veins was not proven in this
way, the position test was carried out. This consists in
setting the patient’s pelvis for a minute in a declined

position, and then in the Trendelenburg position again.
Sixty seven cases of pelvic varices were detected: 47
(70.1%) were bilateral, 10 (16.4%) were on the left
side, and in one case (2.9%) on the right side. The most
frequent localization of pelvic varicose veins was
between the fallopian tube and the ovary. Endometriosis was associated in 13.4%, and adherence in 10.4%
of cases.
Laparoscopy in the Trendelenburg position and
associated with the position test represents a useful
diagnostic method for pelvic varicose veins.

Diagnostic approach to peripheral venous malformations:
the roles of MRI and Duplex scanning
B. B. LEE (Korea)

Venous malformations (VM) are the most frequent
type of congenital vascular malformation, and angiography has been used as the gold standard to decide the
management of these conditions. However, this is an
invasive method with nonnegligible morbidity. The
purpose of this study was to evaluate magnetic resonance imaging (MRI) as a possible new gold standard
for treatment decision in this type of patients. B. B. Lee
studied 196 patients using the MRI study as the initial
procedure, and he carried out duplex scan and WBBPS
(whole body blood pool scan) to characterize the VM.

PHLEBOLYMPHOLOGY 2002

Angiographic methods (preferably in road map form)
were added only for the further differential diagnosis
if indicated. In 174 patients a conclusive diagnosis was
obtained on MRI-based noninvasive tests (positive predictive value 98.9%). Further angiographic tests were
needed for differential diagnosis in 20 patients and
confirm the negative finding of MRI to rule out VM
(negative predictive value 90%) and other situations
such as lymphatic malformations (10 patients).
MRI can replace the role of angiography as the new
gold standard for the diagnosis of predominantly VM.

S49

CHRONIC VENOUS DISEASE
AND VENOUS MALFORMATIONS
Organized by the IUA and the American,
South American, and Latin-American Venous Forums
Moderators: H. SCHANZER (USA) and R. SIMKIN (Argentina)
Chairpersons: J. ULLOA (Colombia), M. De CASTRO SILVA (Brazil)
and E. ENRICI (Argentina)

Long-term results of high ligation and stripping of the great
saphenous vein
E. ENRICI (Argentina)

Relying on data from personal and international
statistics, the authors suggested that a saphenous
stripping operation is the best procedure to guarantee
a low percentage of recurrences.
Analyzing the most frequent causes of recurrent varicose veins after surgery, the main cause appeared to be
the presence of incompetent perforators.
The incidence of unsuspected deep vein system
insufficiency is low, and the occurrence of neoangiogenesis is extremely rare, so the other most important
cause is failure of surgery.

The rate of failure is higher if the long saphenous vein
is conserved.
Numbers of recurrences higher than in conservative
surgery are seen only after schlerotherapy. To operate
on recurrent varicose veins, it is necessary to operate
on incompetent perforators, and if there is deep vein
insufficiency, identified perforators are operated upon
even if normal, as with time they tend to become insufficient.

Long-term results of high ligation without stripping
of the great saphenous vein
A. SHAPIRA (Argentina)

Drawing on their personal experience, the authors
stated that long saphenous vein preservation could
lead to recurrences in a small number of cases and at the
same time prevent nerve injuries and more visible scars.
Their personal experience is drawn from operations on
2260 patients, of whom 1536 were available for longterm follow-up.
While recurrences of almost 90% have been reported
if there is only ligation of the saphenofemoral junction,
using a personal technique, other than CHIVA, that

S50

requires a complete exposure of the common femoral
vein and identification and ligation of all the collaterals and incompetent perforators, the authors obtained
a recurrence rate of only 12%.
Most of the recurrences were due to the persistence of
incontinent leg perforators.
The authors maintain that stripping of the long saphenous vein does not eliminate other sources of reflux.
Persisting reflux in the trunk of the saphenous vein
must not be considered as varicose vein recurrence.

PHLEBOLYMPHOLOGY 2002

Surgical treatment of patients with Klippel-Trenaunay
syndrome
R. SIMKIN (Argentina)

The author described his 30 years’ experience in
operating on patients with Klippel-Trenaunay syndrome.
After illustrating the main characteristics of this syndrome and its variations, he described the different
diagnostic methods to be used, including radiography
of the leg bones, duplex scanning, oxymetry, and above
all arteriography, which is the most important single
examination before surgery.

After using metaphyseal staples for a few years he
developed a skeletization method that includes vein
resection and separation between the arterial and the
deep venous system, and has operated on about
150 patients using this technique.
Choosing patients who did not have diffuse arteriovenous fistulas and operating on them before the age of
15, the authors obtained good results in up to 80% of
the patients.

Subfascial endoscopic perforator surgery:
the Brazilian experience
A. LEDERMAN, E.T. AGUIAR, G. SCHREEN, M.A. FARJALLAT (Brazil)

The authors reported their personal experience in
operating on selected patients with the SEPS technique.
In the last 5 years they operated on 27 patients, obtaining healing of the ulcers in all cases during a period of
from 2 to 15 weeks. In their series they had less than

8% infections and only one ulcer recurrence after 18
months.
They conclude that the procedure can be a safe and efficient way to treat patients with ulcers and perforator
vein insufficiency.

Pathophysiology of venous ulcers
M. DE CASTRO SILVA, (Brazil)

T

he main determinant of ulcers in chronic venous
disease is ambulatory venous hypertension; this will
lead to ulceration through damage to the microcirculation.
Among the many alterations that are probably
involved, we can find deposition of pericapillary fibrin,
abnormality in the number and characteristics of the

PHLEBOLYMPHOLOGY 2002

capillaries, alterations of blood viscosity and of
endothelial secretory function, and leukocyte and
platelet activation.
The relative role of each alteration must still be clearly
identified, and it is a task that will face us in the next
years, with important therapeutic implications, like the
future role of fibrinolytic therapy.

S51

Radiofrequency treatment for perforator surgery
J. ULLOA (Colombia)

T

he author has just begun to use radiofrequency, used
up to now to treat teleangectasias, to operate on incompetent perforating veins in a minimally invasive way.
Using a Teflon-covered needle guided by ultrasound,
he has been able to completely resect perforating veins

S52

under local anesthesia, then use elastic wraps and analgesia for 3 days, followed by compression stockings.
The first results will be published in a short time, but
up to now the author has not observed deep vein
thrombosis or other important complications.

PHLEBOLYMPHOLOGY 2002

Part 6

CONSENSUS MEETINGS

RECENT CONSENSUS DOCUMENTS
AND THEIR PROSPECTS: TASC AND CoCaLIs
Moderators: L. NORGREN, (Sweden) and P. GLOVICZKI, (USA)

TASC

A s R.B. Rutherford pointed out, TASC on PAD is a
consensus document created by the need to obtain a
common definition of critical limb ischemia. It was
initially thought of as a transatlantic, multidisciplinary,
society based on optimum management of limb
ischemia. The work started in 1996 and was published
in the year 2000 as a four-section document, with
107 Recommendations and 47 Critical Issues. Like any
document, it has its problems and strengths. J. A.
Dormandy delineated four possible problems:
• Many of the crucial issues have not been subjected
to proper analysis by randomized controlled trials.
• As medicine is an evolving field, some of the recommendations may become obsolete.

• According to the recent antiplatelet trials, clopidogrel
might be included as the antiplatelet agent of choice
(Rec. 28).
• Recent trials of products like Cilostazol, Pentoxifiline,
or Buflomedil should be revised and updated (Rec. 30)
• Analyse ß-blocker application during the perioperative period.
J. Belch pointed out the fact that claudication (from
arterial problems in the legs) is often considered less
important than myocardial angina and therefore
undertreated. The revision of new pharmacological
agents was divided into three different aspects: symptom management, risk management, and control of
disease progression.

• Such a document may ossify practice and inhibit new
experimental approaches.

Symptom management:

• It may not be universally applicable.

• Nondrug therapies such as photoangioplasty (need
trials).

However it could be argued that, as a consensus
document, it has its strengths:

• Muscle ischemia as l-propionyl carnitine (studies not
yet finished in the applicability on PAD).

• Identifies issues where there is not firm evidence.

• Blood plasma, as hormone replacement therapy (no
clear application on PAD).

• Is based on societies rather than individuals.
• Creates a consensus from often conflicting disciplines.
• Discourages uncontrolled experimentation.
• Raises the general standard of care.
• Considers economics and clinical cost/benefit analysis.
• Is an evolving document.
W. Hiatt analyzed the recommendations on pharmacotherapy, pointing out some improvements to be
made:
• New consensus on diabetes control (Recommendation 23).
• Patients who need lipid-lowering therapies may be
undertreated (Rec. 25).

S54

• Blood cells, as antiplatelet treatment (analyze and
update the recommendations).
Risk management:
• ß-Blockers during the perioperative period.
Control of disease progression: taking into account that
atherosclerosis is a circulatory disorder and an inflammatory disorder too, there should be far more investigations in the antiinflammatory field.
To close the session L. Norgren emphasized the fact that
TASC should be a living consensus and should therefore be continually updated. The common opinion in
the session was the convenience of an Internet version.

PHLEBOLYMPHOLOGY 2002

CoCaLIs

A s D. Clement stated, CoCaLIs is a clinical approach

When talking about the economic factors influencing
the management of the CoCaLIs patient, I. DurandZaleski pointed out that the most costly problem could
be ensuring that patients receive the recommended
treatments and stay in the network of medical control.

to the management of the patient with Coronary
and/or Carotid artery disease who presents with Leg
Ischemia. It does not focus on the treatment of the limb
ischemia, but rather on the best possible approach to
the associated coronary, carotid, and renovascular disease. The initial document did not include renovascular disease, and P. F. Plouin provided an update of this
issue in his presentation. To summarize, the CoCaLIs
patient with resistant hypertension, pulmonary
edema, progressive azotemia, or decrease in creatinine
clearance during ACEI should undergo the algorithm
below (Figure 1).

CoCaLIs patient with:
Resistant hypertension
Pulmonary edema
Progressive azotemia
➘ in Ccr during ACEI

Finally D. Clement presented a summary in management of the CoCaLIs patient, and two proposed
recommendations in PAOD coronary management in
which ß-blockade could be applied when an intermediate or high cardiac risk was detected, or in all types
of patients. Here we show option 2, which was the
most accepted by the audience (Figure 2).

Renal artery CT-angio
MR-angio or Doppler

Aortography
indicated
yes 

Visualize renal arteries
RAS ≥ 60%
or bilatéral

Noninvasive treatment,
6-montly follow-up

no 

yes 

Adapted from Plouin et al.
J Am Soc Nephrol
2001;12:2190.

➘ in Ccr
or kidney length 

Angioplasty ± stent

yes

Figure 1. Algorithm for the management of CoCaLIs patients.

Correct heart failure 

ß-Blockade 

Cardiac risk assessment 

Intermediate/high   

Low

DSE (Thallium)  

Negative

Positive 

Coronary angiography    

Vascular surgery

Medical, PTCA, surgery

Figure 2. PAOD coronary management – Option 2.

PHLEBOLYMPHOLOGY 2002

S55

Part 7

IUA PRIZE

ABSTRACTS PRESENTED BELOW ARE THOSE
BY THE THREE FINALISTS OF THE IUA FELLOWSHIP
Winners are O. PICHOT and collaborators

Duplex imaging analysis of greater saphenous vein reflux:
basis for strategy of endovenous obliteration treatment
O. PICHOT, C. SESSA, J. L. BOSSON
Divisions of Vascular Medicine, Vascular Surgery and Medical Information Science, University of Grenoble, France

Purpose
To characterize greater saphenous vein (GSV) reflux in
order to better define indications for appropriate
endovascular obliteration treatment. Materials and
methods: Color-flow duplex imaging was used to
categorize 132 lower limbs in 102 consecutive outpatients, presenting with chronic superficial vein disease
associated with GSV incompetence characterized by a
>2-second reflux duration. The following parameters
were assessed; saphenofemoral junction (SFJ) morphology and hemodynamics, reflux origin, and GSV
main trunk reflux extent. Results: GSV reflux was
related to partial or complete terminal valve incompetence in respectively 33 (24.8%) and 37 (27.8%) limbs,
to subterminal valve incompetence in 37 (27.8%)
limbs, and to segmental incompetence of the GSV
trunk in 26 (19.6%) limbs. Reflux originated from the
common femoral vein (CFV) into the incompetent SFJ
in 70 (52.6%) or into a thigh perforater in 7 (5.3%)
limbs. GSV reflux arose from SFJ tributary drainage
associated with CFV reflux in 32 (24%) limbs. Circumflex and superficial epigastric veins were involved
in 65.2% and 50.7% of the SFJ tributaries, with a mean

S58

diameter of respectively 3.6 and 3.7 mm, and with a
maximal peak-flow velocity of 13.8 and 16.7 cm/sec.
Drainage of the posteromedial vein or other branches
was the origin of the GSV trunk reflux in respectively
24 (12.8%) and 5(3.7%) limbs. GSV reflux extended
above the knee in 62 (46.5%) limbs, down to the upper
third of the calf in 25 (19.9%) limbs, down to the midthird of the calf in 16 (11.7%) limbs and down to the
ankle in 29 (22%) limbs. The age of the patients was
not correlated with reflux origin, nor with crural reflux
extent.

Conclusions
The preliminary analysis of our study suggests that in
two thirds of cases, endovenous obliteration treatment
limited to the above-knee segment of the GSV could
be suitable. Furthermore, in order to preserve GSV
competent valves and collateral vein drainage, treatment should start just below the main SFJ tributary
when the subterminal valve is incompetent, and just
below the main branch connection when only the GSV
trunk is incompetent.

PHLEBOLYMPHOLOGY 2002

Potential use of D-dimer measurement in patients treated
with oral anticoagultants for a venous thromboembolic episode
E. OMBANDZA-MOUSSA, M. M. SAMAMA, M. H HORELLOU, A. LE CHATELIER, I. ELALAMY, J. CONRAD
Service d’hématologie biologique, Hôpital Hôtel Dieu, Paris, France

T

he measurement of D-Dimers with a clinically
validated method is associated with a high negative
predictive value in the diagnosis of recent venous
thromboembolic episodes (VTE). The duration of anticoagulant treatment in patients with a VTE is not well
established. A subgroup of these patients is at high risk
of recurrent episodes, but their identification remains
unreliable. The persistence of high levels of D-dimers
has also been suggested as a marker of hypercoagulability in rare studies, and might be used to identify
patients at risk of recurrent DVT. We have studied the
influence of oral anticoagulant treatment in 149
patients, 17 to 84 years old, with a history of venous
thromboembolism; 81 received oral anticoagulant
treatment, 68 did not. Patients with known causes for
high level of D-dimer such as cancer were excluded.
Thrombophilia was found in 84 patients. D-dimer
measurements were performed by ELFA technique

PHLEBOLYMPHOLOGY 2002

using the Vidas (bioMérieux, France) analyzer. A significantly lower level of D-dimers was observed in
patients on oral anticoagulants compared with patients
without this treatment, 197 + 134 mg/L versus 399
+ 239 mg/L, respectively (P<0.001). A level over the
normal value (500 mg/L) was found in only 3 patients
out of 81 receiving an oral anticoagulant treatment as
compared with 21 of the 68 patients without treatment. This decrease in D-dimer in patients receiving
oral anticoagulants was the same in the different age
populations. There was no correlation between INR
and D-dimer levels in this study. The clinician should
be informed of the decrease in D-dimer in patients
treated with anticoagulants. The decrease in D-dimer
plasma level during oral anticoagulant treatment
suggests that D-dimer concentration in plasma is an
indirect marker of reduced clotting activity in vivo.

S59

Duplex ultrasound criteria for defining the severity
of carotid stenosis
K. A. FILLIS, F. R. ARKO, B. L. JOHNSON, I. I. PIPINOS, E. J. HARRIS, Jr, C. OLCOTT, C. K. ZARINS
Division of Vascular Surgery, Stanford University Hospital, California, USA

Purpose
Duplex ultrasound scan (DUS) criteria for grading
>50% carotid artery pathology is typically divided into
broad disease groups such as intermediate, severe, and
occlusive lesions. The purpose of this study was to validate DUS criteria for stratifying 50% to 100% carotid
stenosis in 10% intervals, as compared with digital subtraction cerebral angiography (DSCA). Furthermore,
the new velocity criteria were utilized to determine the
clinical management of these patients compared with
angiography.

Methods
Threshold velocity criteria for determining the degree
of carotid stenosis was defined in 7 categories: <50%,
50% to 60%, 60% to 70%, 70% to 80%, 80% to 90%,
90% to 99%, and occlusion. These criteria were compared with DSCA. In cases where duplex velocity criteria did not correlate with angiography, we reviewed
how the angiographic findings altered the surgeon’s
attitude toward surgical or conservative management.

S60

Results
The sensitivity, specificity, positive predictive value
(PPV), and negative predictive value (NPV) for each
velocity criteria category as compared to angiography
were determined. The results are as follows: a)<50%
stenosis; 98%, 95%, 94%, 98%, b) 50%-60% stenosis: 82%, 99%, 85%, 83%, c) 60%-70% stenosis: 91%,
95%, 77%, 96%, d) 70%-80% stenosis: 80%, 99%,
94%, 97%, e) 80%-90% stenosis: 84%, 99%, 91%,
99%, f) 90%-99% stenosis: 95%, 99%, 95%, 99%, g)
occlusion: 100% for all values. There was a high correlation (R=0.96) between duplex scan and angiography in 93% (302/326) of the cases. Clinical management was altered in 3% (10/326) of the cases based on
the results of DSCA.

Conclusions
The DUS velocity criteria to grade the severity of
carotid disease in 10 percent intervals is reliable and
accurate. Clinical management of patients with carotid
stenosis can be based solely on carotid DUS in 97% of
patients considered for treatment of carotid artery
disease.

PHLEBOLYMPHOLOGY 2002

Part 8

LYMPHOLOGY

LYMPHEDEMA AND CHYLOUS DISORDERS
Moderators: C. CAMPISI (Italy) and R. BAUMEISTER (Germany)

Microcirculation and lymphedema
G. THIBAUT, A. DURAND (France)

T

he authors found that in grade III lymphedema there
is a decrease and a slowing of flow.
They used a laser-Doppler, connected to a PC with software able to analyze laser-Doppler recordings.
Twenty-three patients with unilateral lymphedema
were studied, using the normal limb as control, in basal
conditions, during inflation of a thigh tourniquet to
50 mm Hg, and during deflation.

Calculating the minimum and the maximum flow, and
the time interval between these two values, the
affected limb showed values that are consistently
different from the control limb, with a statistically
significant difference.
Different studies have shown that in grade I and II lymphedema the microcirculation is increased, so a probable cause of flow reduction could be the appearance
of fibrosis.

Nonoperative treatment of chronic lymphedema
T. ROOKE (USA)

Lymphedema is a widespread disease, with probably
100 million cases worldwide, especially in developing
countries.
Main reasons for treating this affection in the Mayo
clinic experience are pain in 1% of cases, decreased
mobility in 16%, cosmetic reasons in 44%, and prevention in 39%.
To obtain reduction in limb size, physical methods are
mainly used, such as limb elevation, pneumatic
pumps, and manual lymphatic drainage.

Another main point is maintaining the limb reduction,
and this too is obtained with physical means, mainly
elastic compression, and in a minority of patients with
nonelastic compression.
Diet, diuretics, antibiotics, exercise, and avoidance of
drugs that can exacerbate edema represent supplementary measures.
To tackle such a complex phenomenon, a multidisciplinary effort is mandatory.

Surgical treatment of chronic lymphedema
K. BURNAND, (UK)

T

he author reported his experience in excisional
operations in selected patients where the amount of
lymphedema was such that movement is difficult.
The various procedures, such as the most radical one
proposed by Charles, require cutting away excess skin.

S62

Owing to the small number of patients selected, it is
difficult to assess the results of such interventions, but
from a survey it appears that 77% of patients are happy
with their results.

PHLEBOLYMPHOLOGY 2002

Surgical treatment of primary chylous disorders
P. GLOVICZKI, A. A. NOEL, C. E. BENDER, A. W. STANSON, C. DESCHAMPS, (USA)

C

hylous disorders are a rare condition, with chylous
ascites representing no more that 1 out of 50 000 to
100 000 hospital admissions.
At the Mayo clinic, between 1976 and 2000, 35
patients, 15 men and 20 women, were treated for
primary chylous disorders. Forty percent were subjected to a nonsurgical management, that included
external compression, lymphatic drainage, skin care,
medium-chain triglyceride diet, and diuretics.

The rest underwent various surgical procedures; the
most common was resection of retroperitoneal
lymphatics for patients with lymphangectasia, while
chylous ascites was treated with ligation of the mesenteric or retroperitoneal fistula, and chylothorax
required pleurodesis and leaking lymphatics or
thoracic duct ligation; all patients improved after these
procedures, and more than two thirds had durable
clinical benefit from the operation.

Long-term results of lymph vessel transplantation
for chronic lymphedema
R. BAUMEISTER, (Germany)

Lymphatics are vessels, and so if there is a block in
flow the ideal treatment should be a graft, but in treating vessels with a diameter of 0.3 mm, to be able to perform a lympho – lymphatic anastomosis, micro- and
plastic surgery skills are needed.
With this technique we can treat a localized obstruction, typical of secondary lymphedema, while patients
with the primary disease are usually not suitable for
this treatment.
Vessels to be used as grafts are usually taken from the
bundle of vessels in the thigh: one needs two or three
vessels in postmastectomy lymphedema.
Using this technique the author operated on more than
200 patients, and long-term results show that it is

possible to obtain a good reduction in the volume of
the limbs, up to a 75% reduction, and that the results
are particularly good in the arms.
Even the transport index of lymphoscintigraphy
usually improves.
For the legs, usually two or three vessels are transposed
to the affected limb at the groin.
These patients need medical therapy for some time, but
the grafts appear to maintain their patency for many
years.
Complications appear to be rare, and above all the
donor leg does not show any significant difference after
the operation, so the author suggests operating as early
as possible.

The state of the art of lymphatic microsurgery
C. CAMPISI, (Italy)

A

fter a brief historical summary and the illustration
of the achievements of the pioneers of lymphatic
microsurgery, the author illustrated his own results in
lymphatic surgery, using interposition of a venous tract
to obtain a lymphatic-to-lymphatic anastomosis, especially when there is involvement of both limbs.
PHLEBOLYMPHOLOGY 2002

The author stressed the importance of treating these
patients early, at the first stages of lymphedema, to
obtain the best results.

S63

Part 9

PERIPHERAL ARTERIAL
DISEASE

DIABETES, CRITICAL LIMB ISCHEMIA, AMPUTATION
Chairman: K. ANDREWS (USA)

Carotid artery atherosclerosis according to the ACE I/D
polymorphism in subjects with diabetes mellitus
E. ANDREADIS, E. J. DIAMANTOPOULOS, M. KAKOU, C. VASSILOPOULOS, N. GIANNAKOPOULOS,
K. TARASSI, C. PAPASTERIADES (Greece), A. NICOLAIDES (Cyprus)

Depending

on the echogenic characteristics, the
authors divided atheromatous lesions into predominantly echolucent (PEL), mixed (M) and predominantly echogenic (PEG) with <30%, 30% to 70%, and
>70% of the total plaque area echogenicity, respectively. One hundred and eighty four patients with diabetes mellitus type 2 and with carotid stenosis were

ACE

examined to determine angiotensin-converting
enzyme genotype and common carotid artery intimamedia thickness(IMT).
15.8% of subjects had II, 46,7% had ID and 37.5% DD
genotype.
The echogenicity of the atheromatous lesions is shown
in Table I.

PEG

M

PEL

II

41%

44%

13%

ID

47.7%

34.9%

17.4%

DD

27.5%

37.7%

34.8%

Table I. Echogenicity of atheromatous lesions.

The authors concluded that the patients with DD genotype are more exposed to cardiovascular diseases due to
more echolucent plaques.

S66

PHLEBOLYMPHOLOGY 2002

PATIENTS WITH PERIPHERAL ARTERIAL DISEASE
AND CHANGES IN THE UPPER-LIMB VESSELS
Moderators: P. RICHARDSON (USA), P. VALLENCE (UK)

Intimal thickening of the radial artery
J. WOODCOCK (UK)

The radial artery is usually considered to be free of
atherosclerosis and is commonly used as a conduit in
coronary artery bypass grafting. Recently, a histolological study has shown the presence of intimal hyperplasia and other structural changes consistent with
early atherosclerosis in the radial artery.
Structural changes may be objectively quantified in
vivo by measuring parameters such as:
• intima-media thickness (IMT);
• internal vessel diameter;
• distensibility;
• compliance.
Regarding the IMT measurements on radial artery, a
positive correlation was found between ultrasonic and
histological measurements, in 15 patients (r=0.618;
P<0.014) while in 11 patients there was good correlation between in vivo and in vitro radial artery measurements (r=0.929; P<0.0001).1

• In 1996, Safar et al4 presented the IMT during the
aging process. They found that the increase in internal
diameter and IMT during the aging process can have
opposite effects on the fundamental elastic properties
of large elastic or medium-sized muscular arteries.
• In uncomplicated hypertension a significant increase
in IMT is observed at the radial and carotid arteries;
• In old subjects with systolic hypertension, radial
artery hypertrophy is reversed by drug therapy involving diuretics, converting enzyme inhibitors, or both.
This change occurs in parallel with the reduction in
blood pressure;
In 1999 Bartoletto et al5 found that the ageing process
modified the distensibility of elastic (elderly subjects
had lower distensibility and higher modulus than
young subjects in carotid artery) but not muscular
arteries such as the radial artery.

Girerd et al2 studied, in 1994, 60 hypertensive patients

Finally Mackay et al in 20016 studied the radial artery
in coronary atherosclerosis and concluded that:

of whom 33 had never been treated, and 27 were well
controlled by antihypertensive therapy, and 40 agematched controls

• increased radial artery wall thickness can be demonstrated in vivo in patients with coronary atherosclerosis;

They found that:
• the diastolic intimal diameter did not differ in the
three hypertensive groups;
• wall thickness and the thickness/radius ratio were
significantly higher in the untreated hypertensive
group than in the control group;
• in treated, well-controlled hypertensive subjects, the
thickness/radius ratio were not significantly different
from the controls.
Data from another study3 has shown that hypertension decreases arterial distensibility and systemic compliance in large elastic arteries such as the common
carotid artery. However, in the radial artery, compliance is higher in hypertensive than in normotensive
controls, and elastic modulus of the radial artery wall
material is not increased in patients with essential
hypertension.

PHLEBOLYMPHOLOGY 2002

• increased thickness is independent of blood pressure,
but it is consistent with systemic endothelial dysfunction leading to systemic structural changes.
It was concluded that radial artery IMT is a marker of
early atherosclerosis, and can be used as a screening test.
References
1. Girerd X, Mourad JJ, Acar C, et al. Noninvasive measurement of
medium-sized artery intima-media thickness in humans: in vitro validation. J Vasc Res. 1994;31:114-120.
2. Girerd X, Mourad JJ,Copie X, et al. Noninvasive detection of an increased vascular mass in untreated hypertensive patients. Am J Hypertens. 1994;
7:1076-1084.
3. Laurent S, Girerd X, Mourad JJ, et al. Elastic modulus of the radial artery
wall material s not increased in patients with essential hypertension.
Arterioscler Thromb. 1994;14:1223-1231.
4. Safar ME, Girerd X, Laurent S. Stuctural changes of large conduit
arteries in hypertension. 1996;14:545-555.
5. Bartoletto et al. Reference not available.
6. Mackay A, Hamilton C, McArthur K, et al: Radial artery hypertrophy
occurs in coronary atherosclerosis and is independent of blood pressure.
Clin Sci. 2001;100:509-516.

S67

PERIPHERAL ARTERIAL DISEASE: EPIDEMIOLOGY,
QUALITY OF LIFE, MEDICAL TREATMENT
Moderators: G. M. ANDREOZZI (Italy), H. RIEGER (Germany)

Legs for Life: a screening and educational program
for vascular disease
P. BEATTY (USA)

P. Beatty presented an interesting screening program for peripheral vascular disease.

Peripheral vascular disease (PVD) affects an estimated
8 to 10 million people in the US. Individuals with PVD
are at greater risk for heart attack, stroke, and loss of
limbs, yet awareness among the general public and primary care physicians regarding diagnosis, treatment,
and prevention of this disease is extremely low.
Recognizing this problem, the Society of Cardiovascular & Interventional Radiology (SCVIR) developed
Legs For Life®, a public education/community wellness
program that screens people who may be at risk for
PVD and helps them take the next step in resolving the
pain they are experiencing. The PVD screenings at
participating Legs For Life sites are offered at no charge
as a community service. The program's mission is to
improve the cardiovascular health of people in our
communities.
The primary goals of the Legs For Life program are to
educate the public, to educate primary care physicians
and the medical community, to identify patients at risk,
and to strengthen collaborative relationships among
health care professionals who treat this condition.

• Contacts to primary care physicians: 180 000 prior
to the screenings and 112,595 after the screenings
indicating their patients were screened
• Risk levels of those screened for PVD have
remained consistent: Approximately 1 in 4 individuals were either at moderate or high-risk for PVD.
1999 – 2001
• More than 316 million people reached through
national and local media efforts
• 800 Consumer Line Calls:

98 000

• Legs For Life Web site visits
(www.legsforlife.org):

588 000

• E-mails:

5 200

Health care professionals involved
in Legs For Life 1998 - 2001
• Interventional radiologists:

3099

• Cardiologists:

286

• Vascular surgeons:

1661

• Podiatrists:

291

• Radiology nurses:

1876

• Vascular nurses:

3161

1998 – 2001

• Technologists:

3267

• Individuals screened to date: >202

• Medical students:

• Screened for AAA: 11 000 (2001)

• Other:

• Health care professionals involved: >18 000

Total health care professionals:

Program impact

S68

402
4864
18 907

PHLEBOLYMPHOLOGY 2002

PVD awareness amongst screened patients

2001 Legs For Life Highlights:

1317 patients 6 months after their Legs For Life 2000
screening (62.9% response)

New program components:

• Learned more about PVD through a LFL
screening:

53%

• National roll-out of abdominal aortic aneurysm
(AAA) screening

• Remembered ABI as the name of test given:

79%

• 87% of those told to see their primary
doctor followed up and did so
Recognized PVD symptoms:
• Leg pain:

40.8%

• Numbness in legs:

29.9%

• Cold feet:

30%

• Introduction of national spokesperson Rodney
Dangerfield
• Release of new consumer education video on
PVD/AAA
• Pilot collaboration with Life Line Screening
• Bilingual materials available

Statistics:
Learned more about:
• PVD:

69%

• Approximately 679 Legs For Life screenings were
held at 409 sites

• Leg pain:

61%

• 121 of the Legs For Life sites screened for AAA

• Diabetes:

67%

• Heart disease:

38%

• More than 5826 medical professionals collaborated
to screen more than 55000 patients for PVD

Recognized PVD risk factors:
• Smokers:

48.2%

• Overweight:

44.8%

• Age (over 50):

41.4%

• Diabetes:

39.8%

Risk factor awareness:
• Exercise:

60%

• Weight:

55%

• Smoking:

48%

• Diet:

46%

• 75% of sites participated in previous year(s), and
70% of members participated in previous year(s)
• 25% of those screened were found to be at either
moderate or high risk for PVD (high risk – 6% and
moderate risk – 18%)
• 1 in 5 were found to be at risk for AAA using questionnaire only
• 1 in 4 were found to be at risk for AAA using questionnaire and ultrasound
• 149 370 consumers visited the Legs For Life Web
site, and more than 45 000 called the Society’s toll
free patient information number.

Program components:
• Site recruitment, training, and technical assistance
• Public education and awareness
• Professional education and awareness
• Program evaluation
• Program oversight and management

A Web site was created for more information:
www.LegsForLife.com

PHLEBOLYMPHOLOGY 2002

S69

Disease-specific quality of life (QOL) analysis: is it necessary
in patients with claudication?
P. A. COUGHLIN, I. C. CHETTER, P. J. KENT, D. C. BERRIDGE, D. J. SCOTT, R. C. KESTER (UK)

In this study the authors assessed in 91 patients the
effect of increasing disease severity on QOL (two disease specific:CLAUS and Kings Vacuqol and two
generic: the Short Form 36 and the EuroQoL ) and
analyzed the responsiveness of these instruments to
QOL changes in patients with claudication.
The patients had mild, moderate, or severe intermittent claudication.
The QOL domains : pain, physical activity, psychological and social status.

S70

They concluded that:
• QOL deteriorates with increasing intermittent claudication
• All QOL tools are responsive to changes in both physical activity and pain
• The disease-specific QOL tools are more responsive
to changes in psychological and social well-being.
Finally they commended the inclusion of disease-specific instruments in the QOL analysis of patients with
intermittent claudication.

PHLEBOLYMPHOLOGY 2002

PHARMACOTHERAPY FOR PERIPHERAL
ARTERIAL DISEASE
The 3rd transatlantic vascular medicine symposium
VASCULAR BIOLOGY
Chairpersons: L. NORGREN, J. BELCH, A. HIRSCH

The prevalence and natural history of PAD:
a rationale and primer for PAD pharmacotherapy
J. DORMANDY (UK)

Peripheral arterial occlusive disease (PAD) is well
known as a major risk factor for cardiovascular morbidity and mortality. Nevertheless, there is more left
unknown, and a list of remaining questions appears
below.
Is PAD a continuum from the total population to the
amputee?
What is the history of patients with chronic critical limb
ischemia (CLI) before they develop it?
What are the risk factors for macrovascular disease in
diabetics?
In contrary to the decreasing mortality rates for other
cardiovascular risk factors, death rates in diabetics are
still increasing independently of other cardiovascular
risk factors and duration of diabetes.

Risk factors such as diabetes, smoking, ankle-brachial
pressure index, age, and lipids only explain in part the
risk of cardiovascular morbidity and mortality in PAD.
Even if risk factors are adjusted for and ischemic heart
disease excluded, PAD has an increased risk for cardiovascular mortality and myocardial infarction. This
means there must be more that increases relative risk
of total mortality and cardiovascular morbidity in PAD.
What are the predictors of poor prognosis in early PAD?
Is “subcritical” leg ischemia really a subentity?
What is the effect of standard management on outcome?
In summary there must be more factors involved in the
prognosis of patients with PAD than the standard risk
factors of which we are all aware.

What is the magnitude of effect of individual risk
factors on PAD/CLI?

Pathophysiology of claudication
W. HIATT (USA)

M

easurable hemodynamics such as the anklebrachial index (ABI) at rest do not ultimately predict
function. There is a well-noted lack of correlation
between ABI and treadmill testing. In addition bypass
surgery/angioplasty do improve ABI but do not always
normalize function, as exercise training does not
improve ABI but may improve function.
A factor underrecognized in the past is changes in
skeletal muscle metabolism based on microcirculatory

PHLEBOLYMPHOLOGY 2002

changes and generation of oxygen free radicals. The
primary event thus is a reduced pressure and flow that
secondarily is followed by changes in muscle metabolism inducing functional impairment and possible irreversible muscle injury.
Further reading
J Cardiopulm Rehabil. 1988;12:525-532.
Hiatt WR, Wolfel EE, Regensteiner JG, Brass EP. J Appl Physiol. 1992;73:
346-353.
Brass EP, Hiatt WR, Gardner AW, Hoppel CL. Am J Physiol. 2001;280:H603-609.

S71

Measuring clinical outcomes: claudication
(Report of the transatlantic Guidelines)
K. H. LABS (Switzerland)

C

lassical end points in clinical trials concerning intermittent claudication are treadmill testing and quality
of life assessment. Based on some well conducted studies, absolute claudication distance (ACD) serves best as
a primary end point, whereas initial claudication
distance (ICD) and quality of life assessment should be
restricted to serve as secondary end points. With regard
to the treadmill protocol, data show that graded as well

as constant loads are reliable if claudication distance is
more than 300 ft at entry. In case of short walking
distance (< 300 ft) graded protocols give better reliability.1-2
References
1. Labs KH, Nehler MR, Roessher M, Jaeger KA, Hiatt WR. Vasc Med. 1999.
2. Discher et al. J Vasc Surg. 2002.

Measuring clinical outcomes:
CLI (Report of the transatlantic Guidelines)
F. MONETA (USA)

C

hronic critical leg ischemia is difficult to categorize,
and trials are difficult to conduct. With regard to
pharmacological trials, inclusion is mostly restricted to
patients not suitable for surgical or catheter-based
revascularization. The definition of unreconstructable,
however, varies with the surgeon, center, ethics, or
judgment, and in experienced centers nearly all
patients can be revascularized, excluding them from a
potentially favorable adjunct medical treatment.

S72

Surgery and definitions of success by itself are problematic, because of the very strict criteria defined to
reflect ideal result and that rarely can be fulfilled (alive,
without complications, primary bypass patency, limb
salvage, wound healing, no recurrence of ischemia,
and no need for reoperation). By having these criteria,
only a small percentage of patients have an ideal result.
Definitions, however, should be adapted to patients
with considerable comorbidities to reflect what can be
expected (assisted patency, limb salvage, alive).

PHLEBOLYMPHOLOGY 2002

ESTABLISHED THERAPIES FOR CLAUDICATION
Moderators: D. CLEMENT (Belgium), E. HOUSELY (USA)

Role of lifestyle and exercise interventions
A.HIRSH (USA)

T

he author stressed the point that so far no pharmacologic therapy for the treatment of intermittent claudication has been as effective as the reduction of risk
factors by changing the lifestyle and consequent exercise programs.
Exercise programs are known to be effective in improving walking ability and physical functioning. They are
safe, without any record of morbidity or mortality.
The best results are achieved with supervised exercise
at least three times per week, but patients have to be
motivated and compliant. In order to be effective this
has to be continued for 3 to 6 months. The author cited

studies showing an improvement of 180% in pain-free
walking distance after 6 months of supervised training.
A community survey on 347 patients with risk factors
or limb pain found 27% to have an ABPI< 0.85.Only
6.5% had a history of enrollment in a controlled training programme. Also, there is a high rate of dropouts
in these programs due to the fact that they are timeconsuming and need a lot of motivation on the part of
the patients. These programs are cost-effective when
compared with pharmacological therapy, and even
more so when compared with invasive procedures.

Role of revascularization in the treatment of claudication
M. JAFF (USA)

T

he author presented a study on 2777 patients with
intermittent claudication. The mean follow-up was 47
months. The annual mortality of this group of patients
was 12%; 66% of these died due to their heart disease.
The amputation rate was < 10% over 10 years, and the
revascularization rate 18% over 10 years.
He presented further conflicting data on the effectiveness of interventional therapy and peripheral bypass
operations in patients with claudication and in patients
with critical limb ischemia.
In 526 patients with claudication, interventional therapy was performed in 20% of the cases. PTA and surgery showed a significant improvement in ABPI as well
as in pain, walking distance, and physical functioning
when compared with medical therapy.

PHLEBOLYMPHOLOGY 2002

Another study on infrainguinal bypass procedures in
20 ambulatory patients with critical limb ischemia
failed to show a significant benefit concerning walking
distance and walking speed.
In conclusion it was stated that aortoiliac revascularization is the most reasonable strategy for effective
treatment of claudication, endovascular therapy being
the first method of choice. Infrainguinal revascularization should be used sparingly for intermittent claudication, and the corner stones of treatment remained
risk factor modification, exercise programs, and
antiplatelet therapy.

S73

Part 10

THROMBOTIC
DISORDERS

CURRENT ASPECTS OF DEEP VEIN THROMBOSIS
Chairpersons: J. J. MICHIELS (Belgium), H. RIEGER (Germany)

Leg compression and ambulation are better than bed rest for the
treatment of symptoms of acute proximal deep vein thrombosis
H. PARTSCH (Austria)

Partsch and coworkers began a prospective, random-

and thrombus development. The trial started in 1998
with the following design:

ized study to evaluate the outcome of acute proximal
vein thrombosis (DVT) with regard to local symptoms

Randomized, controlled trial
Proximal DVT   

Bed rest/no compression
(n=17)

Stockings/walking
(n=18)

Inelastic bandages/walking
(n=18)

All patients were treated with dalteparin 200 IU/kg/24 h sc once daily.

There was a significant decrease in calf circumference
measured at day 0, 3, 6, and 9 in both compression/walking groups as well as pain analyzed by visual
assessment score and the Lowenberg test. Thrombus
length was shown to progress in 36%, 25%, and 17%
in the bed rest/no compression, stockings/walking and
inelastic bandage/walking group, respectively.

S76

In conclusion, in acute-phase DVT, compression and
walking is active therapy that provides faster and more
intense relief of pain. There was less thrombus extension and therefore a lowered risk of pulmonary
embolism (PE).

PHLEBOLYMPHOLOGY 2002

Introducing controlled outpatient management (COM)
of deep venous thrombosis in Germany – a feasibility study
with 827 patients
H. E. GERLACH (Germany)

W

ith the new option of outpatient treatment in
patients with deep vein thrombosis (DVT) a wide training program for physicians was started in Germany.
Based on data from this program the rate of hospital
admissions was reduced to 23.7%, whereas 76.3%
(n=631) patients were fully treated on an outpatient
basis. With regard to the duration of symptoms, only
patients with preexisting symptoms for more than 14
days had a slight advantage for faster symptom relief
with hospital admission. The rate of symptomatic pulmonary embolism was not significantly different in

patients treated on an outpatient or inpatient basis. In
a subgroup analysis it was shown that patients with
iliofemoral DVT were treated as inpatients in 62% of
cases, reflecting the still existing fear of fatal PE with
ambulatory treatment. Compliance was shown to be
very good, with 96% injecting LMWH and 80% of
patients wearing stockings.
In conclusion, there is still a need for a physician training program to lower rates of inpatient treatment for
DVT that is shown to be safe and efficient.

Outpatient treatment of deep vein thrombosis: selection
of patients and management of symptoms
with leg compression – a feasibility study
W. BLÄTTLER (Switzerland)

There were 2 prospective series on deep vein thrombosis (DVT) and personal experiences with outpatient
treatment presented by the author. The low-molecular-weight heparin (LMWH) dalteparin (200 U/kg
body weight once daily) and phenprocoumon were
used as anticoagulants. The selection process was monitored in 156 consecutive patients, and the practicability and quality of outpatient treatment in 202 consecutive cases followed over 4 years. All distal DVTs were
treated as outpatients. Of proximal DVTs 11% were
admitted to hospital (9% for thrombectomy or thrombolysis and 2% for conservative treatment). One hundred percent of the dalteparin injections were done as

PHLEBOLYMPHOLOGY 2002

prescribed (5% by a nurse at home). Leg compression
was achieved with class II calf size stockings in 120
patients representing 80% of distal, 50% of popliteofemoral, and 29% of pelvic DVTs. Bandages were
used for the first 5 days in 57 patients, most often
because of too much edema/pain or superficial
phlebitis. Compliance with stockings was 94% after
4 weeks.
In conclusion, outpatient treatment of DVT is feasible
for most patients, and is effective and safe. Compliance
with wearing stockings is high, and the treatment
presumably satisfying.

S77

Venous thromboembolism and cancer – new insights?
V. V. KAKKAR (UK)

A recent increase in interest in cancer and heparin
therapy has resulted from observations made during
prospective, randomized clinical trials, designed to
assess the efficacy and safety of heparin in prophylaxis
and therapy of venous thromboembolic disease (VTE).
Questions that arose when analyzing those trials
further in depth were whether VTE is more aggressive,
whether VTE adversely affects outcome in cancer
patients, and whether antithrombotic therapy can
impact cancer outcome.

Evidence that there are differences in cancer patients
with VTE compared with noncancer patients derive
from various sources of data. Recent studies have
confirmed that cancer patients with VTE have significantly higher levels of F1 +2, D-dimer, FXIIa, and TFPI
that remain elevated even on therapy. VTE also were
shown to be more aggressive and harder to treat by
comparing thrombus load in patients with or without
cancer (Tables I, II).

Patients without
cancer

Patients with
cancer

P value

25
(CI 95% 17-30)

26
(CI 95% 21-31)

<0.01

Ratio prox/total thrombus (%)

34%

38%

< 0.01

Phlebographic response (3 wks)

50.5%

38.7%

< 0.01

Deterioration

5.8%

9.9%

< 0.01

Recurrent VTE

3.0%

10.2%

< 0.01

Initial Marder Score

Table I. Severity of VTE according to presence of cancer.

Patients without cancer

LMWH
39/1481

Patients with cancer

UFH*
41/1471

LMWH
46/306

OR 0.94 (0.6 – 1.47)

UFH
71/323

OR 0.61 (0.40-0.93)
in favor of LMWH compared with UFH

* Unfractionated standard heparin.

Table II. Mortality at 3-month follow-up and DVT treatment. Meta-analysis (9 studies, 1992-97).
In a large observational study by Haas and coworkers it was also shown that prophylaxis of VTE is less efficient
in cancer patients (Table III).

Patients without
cancer

Patients with
cancer

(n=16.954)

(n=6.124

Death

0.7%

3.1%

0.0001

Fatal pulmonary embolism

0.09%

0.31%

0.0001

8%

14%

0.0001

In-hospital mortality

P value

Table III. Results of the observational study by Haas et al.

S78

PHLEBOLYMPHOLOGY 2002

More recently a prospective study was published,
showing that prophylactic use of LMWH for 7 days
while patients with breast or pelvic cancer (n=324) are
on chemotherapy had the ability to prolong survival
even without established VTE. Death rate at 650 days
was 8.7% vs 28.6%, with and without prophylactic use
of LMWH (RRR 0.3 [CI 95% 0.1-0.8], P=0.01).

Based on the accumulating evidence that VTE is more
aggressive in cancer patients, that thrombosis may
adversely affect cancer outcome, and that heparin may
prolong survival, a prospective study comparing
dalteparin (5000 IU/d) vs. placebo in advanced solid
tumor malignancies was initiated recently.

Low-molecular-weight heparins – clinical trial update
S. HAAS (Germany)

Prophylaxis

with low-molecular-weight heparins
(LMWH) has significantly contributed to the reduction
of venous thromboembolic complications in surgical
and nonsurgical patients. Several meta-analyses published between 1995 and 20011-5 indicate that LMWH
(once daily) are as efficient as unfractionated standard
heparin (UFH) in preventing postoperative deep vein
thrombosis (DVT) in general surgery and are more
efficient compared with UFH in preventing DVT in
orthopedic surgery und treating established venous
thromboembolic disease. Extended out-of-hospital
LMWH prophylaxis after major orthopedic surgery was

PHLEBOLYMPHOLOGY 2002

shown more recently to significantly reduce phlebographically verified DVT (7.9% vs 22.5%, P<0.001)
and symptomatic VTE (1.4% vs 4.2%, P<0.001).
References
1. Mismetti P, Laporte S, Darmon JY, Buchmuller A, Decousus H. Br J Surg.
2001;88:913-0193.
2. Mismetti P, Laporte-Simitsidis S, Tardy B, et al. Thromb Haemost. 2000;
81:14-19.
3. Hull RD, Pineo GF, Stein PD, et al. Ann Int Med. 2001;135:858-869.
4. Lensing AW, Prins MH, Davidson BL, Hirsh S. Arch Inter Med. 1995;
601-607.
5. Breddin HK, Hach-Wunderle V, Nakov R, Kakkar VV. N Engl J Med. 2001;
344:626-631.

S79

NEW DEVELOPMENTS IN THE MANAGEMENT
OF THROMBOTIC AND VASCULAR DISORDERS I
Chairpersons: S. GOLDHABER (USA), A. SASAHARA (USA), J. FAREED (USA)

Newer concepts in the understanding of thrombosis;
impact on anticoagulant therapy
J. FAREED (USA)

T

hrombogenesis is influenced by various mechanisms
spanning from cellular activation, and expression of
adhesion molecules to complex regulations of the
plasma coagulation system, with a variety of new
treatment options (Figure 1).
Unfractionated heparin (UFH) has enjoyed sole anticoagulant status for nearly 50 years. Disadvantages of
UFH are bleeding, heparin-induced thrombocytopenia
(HIT), poor bioavailability due to interactions, and a
broad biological activity based on a heterogeneous
mixture of differently sized molecules. Current management of thrombosis is strongly influenced by the
development of newer anticoagulant and antithrombotic drugs. The development of low-molecularweight heparins (LMWH) represents a refinement for
the use of heparin. These drugs represent a class of
polymerized heparin derivates with a distinct pharmacological profile that is largely determined by their

composition. To a large extent the LMWH have
replaced UFH in most subcutaneous indications.
Nevertheless, it should be underlined that properties
of various LMWH cannot be extrapolated to each
other, and results of studies should not be simply
generalized (ACCP recommendations 2001).
Side effects of heparins have necessitated the development of alternate drugs, the synthetic and biotechnology-derived heparinomimetics. Now under evaluation
are pentasaccharides (indirect) FXa inhibitors, peptidomimetics (direct) FXa inhibitor, and the thrombin
(FII) inhibitors (Figure 2).
All new antithrombotic developments have a more
specific action compared with heparin, and it remains
to be clarified whether this will become an advantage,
or possibly limits their indication. Now UFH and
LMWH remain the drugs of choice for most indications.

Fibrin
Thrombin 

TAFI 

TAFIa 

Thrombomodulin complex

Change into nondigestible clots

* By the action of TAFIa, lysis of older clots becomes impossible

Figure 1. Role of tissue activating factor inhibitor (TAFI) in thrombogenesis.

Anti FXa

Heparinomimetics

Anti FVIIa

Antithrombin
New developments

Viscosity modulator

Antiplatelet drugs
Serpins

Anti-TF

Figure 2. Development of new antithrombotics.

S80

PHLEBOLYMPHOLOGY 2002

TFPI as a novel antithrombotic agent
D. HOPPENSTEADT (USA)

Tissue factor (TF) plays a crucial role in arterial,
venous, and microvascular thrombogenesis. Heparin
and defibrotide are capable of releasing an endogenous
inhibitor of TF, which is known as tissue factor pathway inhibitor (TFPI), whereas new antithrombotic
(FXa and FIIa inhibitors) and antiplatelet drugs do not
release TFPI. Therefore there are some theoretical considerations for an adjunct TFPI administration with
these new-generation anticoagulants. Total and free
TFPI has been shown to vary in some disease processes
(eg, sepsis), it shows drug interactions (eg, heparin), is

age-dependent, and increases with mechanical vessel
wall injury or exercise. TFPI exerts its action by first
binding to factor Xa (FXa) and forming a TFPI-FXa
complex, which then, in a second step, binds and effectively inhibits the tissue factor (TF)-factor VIIa (FVa)
complex that has antiplatelet, antithrombotic, anticoagulant, anti-inflammatory, and antiproliferative
effects.
Currently a recombinant version of TFPI, Tifocogin“
(Pharmacia) is in clinical development for various indications (Table IV).

Sepsis

No clear evidence of efficacy (1 positive, 1 negative trial)

Percutaneous interventions

Excessive bleeding

Acute coronary syndrome

Limited experiences

Adjunctive administration

Trials in development

Table IV. Clinical development (TFPI; Tifocogin®).

AXa drugs and antithrombotics: replacement of heparin
B. KAISER (Germany)

Factor Xa (FXa) has a central position in the coagulation system, with a naturally extremely low catalytic
activity. There is a strong amplification of its activity
after assembly with the prothrombinase complex. An
effective indirect inhibition of FXa is achieved by pentasaccharides and synthetic, structurally modified
analogs. Despite the demonstrated effectiveness of FXa
inhibitors (pentasaccharid, Arixtra®) for the prophyInhibition of the tissue
factor pathway of coagulation

Inhibition of the key
enzymes of anticoagulation

FIIa

FXa 

inhibitors

Platelet function
inhibitors    

TFPI

laxis of thromboembolic events in patients undergoing
major orthopedic surgery, a general assessment of the
therapeutic potential of this new class of drugs has to
consider various additional aspects. These include
pharmacokinetic characteristics, half-life, metabolic
transformations or excretory routes, interactions with
other drugs, and the efficacy/safety profile as well as
the neutralization in case of overdose or side effects.

Clopidogrel, GPIIb/IIIa
receptor blocker

• Inhibition of protein C pathway
• Rebound phenomenon after cessation
• Hemorrhagic complications

Figure 3. New antithrombotics and platelet inhibitors.
Questions remain as to what is the best, and whether more specific anticoagulants such as FIIa and FXa inhibitors
are better than the heparins.
PHLEBOLYMPHOLOGY 2002

S81

A survey of antithrombin agents for the prophylaxis
and treatment of thrombosis
S. HAAS (Germany)

T

oday there is a considerable competition in new
antithrombotic drug developments, in particular with
targeted activities such as FIIa (thrombin) inhibitors
and FXa inhibitors. In various clinical studies, hirudin
prophylaxis (15 mg sc bid) has provided a significant
superior antithrombotic effect when compared with
unfractionated heparin (UFH) or LMWH without significantly increasing bleeding. In addition, hirudin and
hirulog have been tested for initial treatment of DVT.
However, these substances have not been registered for
this indication. Hirudin has only been registered for
treatment of thromboembolic complications that occur
in patients with heparin-induced thrombocytopenia.
A major achievement has been made by the development of the oral direct thrombin inhibitor melaga-

tran/ximelagatran that potentially may replace both
heparins and vitamin K antagonists for the prophylaxis
and treatment of thrombosis.
The THRIVE I trial, a phase II dose-finding study
comparing oral ximelagatran 2x24 mg up to 2x60 mg
vs dalteparin followed by OAK in patients with DVT
gave an efficacy comparable to standard therapy with
a wide therapeutic window. There were no serious
bleeds, there was no monitoring of oral therapy
needed, and there were no antibodies shown. In
addition, ximelagatran was shown to inhibit clotbound thrombin. The TRIVE II trial is an ongoing phase
III trial further testing the efficacy and safety of
2x36 mg oral ximelagatran in a larger patient population with DVT.

Warfarin oral thrombin inhibitors and LMW heparins:
which is the best?
R. HULL (Canada)

The

Sixth ACCP Consensus Conference recommended the use of low-molecular-weight (LMWH)
heparins or vitamin K antagonists for the prophylaxis
of venous thromboembolic events (VTE) in patients at
risk. Extending out-of-hospital LMWH therapy may
further reduce VTE in patients at very high risk, such
as those undergoing hip replacement. Because of
uncertainties regarding cost-effectiveness this remains
a 2A recommendation. Vitamin K antagonist prophylaxis is common practice in the USA and Canada for
patients undergoing elective hip replacement. However, clinical trials have shown that vitamin K antagonists are inferior to LMWH in the prevention of VTE.
Discussions about end points in clinical trials such as
assessment of pulmonary embolism (PE) and relevance
of asymptomatic deep vein thrombosis (DVT) can be
clarified in that proximal DVT is identified by epidemiological data as a significant risk factor for PE. Secondly,
with regard to asymptomatic DVT, again there is epidemiological data showing that asymptomatic DVT is
a risk factor for the development of postphlebitic syndrome. Therefore by lowering the asymptomatic DVT

S82

rate, the rate of postphlebitic syndrome will decrease
as well.
A new concept presented by Hull1-2 to lower the persisting VTE rate in high-risk patients despite prophylaxis is the “just-in-time” administration of LMWH.1
Administration of half the regular dose of LMWH close
to the surgery (4 to 6 h postoperatively) followed by
full-dose prophylaxis 12 hours later was shown to be
more effective than current practice with a relative risk
reduction of about 50%, and without increased bleeding rate. The “just-in-time” concept is also in accordance with the current understanding of VTE pathogenesis as an on-the table surgical event. Comparison
with the direct thrombin inhibitor ximelagatran
showed it to be inferior to enoxaparin in the prevention of VTE when started 12 to 24 hours postoperatively this underlines once more the importance of an
early initiation of prophylaxis and adequate study
design in prevention trials.
References
1. Hull R. Arch Intern Med. 2000;160:2208-2215.
2. Hull R. Arch Intern Med. 2001;161:1952-1960.

PHLEBOLYMPHOLOGY 2002

DVT and pulmonary embolism: what are the current
guidelines?
S. GOLDHABER (USA)

ACCP recommendations (Chest. 2001;119:1765-1935.)
A. Low-molecular-weight heparin (LMWH) offers
major benefits of convenient dosing and facilitating outpatient treatment of venous thromboembolism (VTE). LMWH have shown slightly less
recurrent VTE and may offer a survival benefit in
cancer patients as compared with unfractionated
heparin (UFH).

B. In massive pulmonary embolism (PE) or deep vein
thrombosis (DVT) use of heparin is recommended
for 10 days.

C. Duration of secondary prevention with vitamin K

D. Thrombolytic therapy in VTE needs to be a “highly
individualized” decision.

E. Cava filter placement should be restricted to
patients with contraindications for anticoagulation, true failure of anticoagulation, and as an
adjunct to surgical embolectomy.
In general there is need for continuous education, written prophylaxis protocols, clarification that ASS is
insufficient to prevent VTE, motivation to combine
medical prophylaxis with stockings, and that extended
outpatient treatment may be indicated in high-risk
patients (ie, hip surgery).

antagonists needs to be individualized in patients
with established VTE:
reversible or time-limited risk factor ≥ 3 months
calf vein thrombosis ≥ 6 to 12 weeks:
recurrent, idiopathic VTE, cancer, antiphospholipid antibody syndrome ≥ 12 months.

PHLEBOLYMPHOLOGY 2002

S83

NEW DEVELOPMENTS IN THE MANAGEMENT
OF THROMBOTIC AND VASCULAR DISORDERS II
Chairpersons: S. HAAS (Germany), J. SHIMOURA (Japan)
Moderator : L. R. NOGALES (USA)

Current concepts in the management of heparin-induced
thrombocytopenia
J. M. WALENGA (USA)

H

eparin-induced thrombocytopenia (HIT) is an
immune reponse to heparin resulting in platelet activation, aggregation, thrombin generation, and
endothelial cell damage. It leads to a fall in platelet
counts, and can result in limb- or even life-threatening thrombosis (“white clot syndrome”).
Removal of heparin does not result in cessation of the
symptoms, and approximately one third of the patients
suffer a fatal outcome, irrespective of stopping heparin
early.
Antithrombotic therapy is necessary in these patients,
and a review of possible substances was given by the
author: Vitamin K antagonists have a limited value at
the start of the treatment, as they require a loading
dose, leaving patients unprotected in the initial phase.
Danaparoid Orgaran® is effective but needs high doses,
resulting in an increased rate of bleeding complications. Monitoring is inconvenient, as factor anti Xa levels have to determined. There is no antidote available
and a 15% risk of cross reactions with heparin has been
found.

S84

Low-molecular-weight heparins (LMWH) alre less
likely than heparin to cause HIT. They cannot be used
in cases of HIT, as antibodies against heparin would recognize LMWH leading to the same symptoms.
Argatroban Acova® is now approved in the USA,
Canada, and central Europe for the treatment of HIT
and prophylaxis against DVT. Argatrobam is a direct
thrombin inhibitor, is of rapid onset, has a short halflife, and is excreted via liver metabolism. There are no
antibodies, and no known cross reactions with
heparin.
Lepirudin Refludan® is also a possible alternative in the
treatment and prophylaxis of DVT. It is a direct thrombin inhibitor, and has longer half-life compared with
argatroban. The excretion is via the renal pathway, and
antibodies to lepirudin have been found.
A combination of a thrombin inhibitor with an
antiplatelet drug like a GPIIb/IIIa antagonist might
increase the efficacy of treatment in this condition.

PHLEBOLYMPHOLOGY 2002

Antiplatelet drugs in vascular medicine and surgery:
the real role of aspirin
H. K. BREDDIN (Germany)

A

cetylsalicylic acid (ASA) has been used worldwide
in recent years as a platelet function inhibitor for the
prevention of coronary heart disease, cerebrovascular
disease, and peripheral arterial occlusive disease. The
first studies used ASA in high doses (1000-1500 mg/d).
Only recently has it been shown that smaller doses are
also effective without producing side effects.
While large studies have shown beneficial effects of
ASA on coronary heart disease and cerebrovascular
disease, there is still a lack of data on peripheral arterial occlusive disease (PAOD).

PHLEBOLYMPHOLOGY 2002

Two ADP receptor antagonists, ticlopidine and clopidogrel have been shown to be effective in different trials. The combination therapy of clopidogrel and ASA
has been shown to be even more effective leading to
an average risk reduction of 23% in stroke and
myocardial infarction.
According to the author the evidence of the efficacy of
GP IIb/IIIa ihibitors is so far not conclusive.

S85

NEW DEVELOPMENTS IN THROMBOSIS MANAGEMENT II
Chairmen: U. CORNELLI (Italy), O. IQBAL (USA)

Anticoagulant and bleeding effects of low-molecularweight heparins at surgical and interventional dosages
can be effectively neutralized by heparinase
O. IQBAL, D. A. HOPPENSTEADT, P. PICCOLO, Q. MA, A. DAUD, H. L. MESSMORE, J. M. WALENGA, D. FAREED (USA)

Heparinase as an antagonist to prevent hemorrhagic
complications involved with heparins and other
heparin-derived oligosaccharides
O. IQBAL, C. SCHULTZ, D. A. HOPPENSTEADT, M. BAKHOS, J. FAREED (USA)

Although protamine sulfate has been successfully
used to neutralize the anticoagulant effects of heparins,
the same effect was only partialy observed in neutralization of low-molecular- weight heparins (LMWH).
The results of the experimental study shows that
heparinase I may be used as an antagonist of LMWH
without adverse effect of protamine sulfate to prevent
the hemorrhagic complications.
Heparinase I is isolated from the bacterium Flavobacterium heparinum.
By means of thromboelastography(TEG), activated
clotting time (ACT), in vitro supplementation studies,
global clotting assays and animal models the authors
studied heparinase I’s possibility of neutralization of
the anticoagulation effect of LMWH, pentasaccha-

S86

rides, and other oligosaccharides, and compared their
differential neutralization with protamine sulfate and
platelet factor 4.
The authors performed in vitro studies that were confirmed by in vivo models (the rabbit ear blood loss) and
observed an anitcoagulant effect in oligosaccharides
which was neutralized by heparinase and less by protamine sulfate and platelet factor 4. They also stated
that heparinase I neutralized the anticoagulant effects
of the pentasaccharide and hexasaccharide. Compared
with the anti-Xa effects, the anti-IIa effects of LMWHs
and heparin-derived oligosacharides are more effectivelly neutralized by heparinase I.
The authors emphasized that although heparinase I an
be used as an antagonist of LMWH to avoid hemorrhagic complications, it still needs more clinical trials.

PHLEBOLYMPHOLOGY 2002

Turbulent flow of plasma promotes thrombolysis
of nonocclusive blood clots – A MRI study in vitro
A. BLINC, M. STRUKELJ, I. SERSA (Slovenia)

T

hrombolysis creates recanalization channels, leaving large parts of the clot nondissolved, which poses a
potential source of rethrombosis. In the in vitro study
the authors determined how thrombolysis depended
on penetration of plasma containing thrombolytic
agents – rt-PA and streptokinase (SK) under conditions
of turbulent or laminar tangential flow. They performed 20 serial spinecho MRI in 40 minutes to measure the transport of plasma labelled by Gd-DTPA into
clots and to measure the remaining clot size on transverse cross-section.

PHLEBOLYMPHOLOGY 2002

They stated that when SK at 250 IU/mL was used, turbulent flow reduced the cross-section of clots after 40
minutes to 34+/-18% whereas the laminar flow left the
clots unaffected. After 40 minutes of exposure to rapid
flow of plasma containing 2 mg/mL rt-PA, the crosssection of clots was completely dissolved in contrast to
laminar flow where is 86+/-5% of the cross-section of
clots left.
The concluded that the rapid turbulent flow of plasma
allows faster lysis of clot especially by fibrin- specific rt-PA.

S87

REDEFINING THE MANAGEMENT OF THROMBOTIC
DISORDERS: ROLE OF SELECTIVE FACTOR Xa INHIBITION
Moderators: D. CLEMENT (Belgium) and S. NOVO (Italy)
With the participation of: K. Bauer (USA), B. Eriksson (Sweden), G. Agnell (Italy), H.Buller
(The Netherlands)

The incidence of thromboembolic problems in ortho-

III assays for DVT-PE prophylaxis in patients operated
for knee or hip arthroplastys (5385 patients), with the
following results when compared with enoxaparin
treatment (Table V).

pedics and in surgical cancer-related pathology
remains a significant clinical problem. There is also
great concern for the need of an extended prophylaxis
for venous thromboembolism (VTE) after the patients
are sent home. The session was devoted to the study
of the new synthetic antithrombotic, pentasaccharide.

In these studies, the incidence of clinically relevant
bleeding and death was low and similar between
treatment groups.

Pentasaccharide is the first of a new class of synthetic
antithrombotic agents, with anti-Xa specific action.
The drug doesn’t interact with PF4, and therefore it
does not produce thrombocytopenia. It has 100%
bioavailability with predictable effects after subcutaneous injection. It has no effects on APTT, ACT or INR,
but shows a linear effect in the anti-factor Xa assay. In
recent years it has been tested in several phase II and

Other studies in DVT/PE prophylaxis are ready to
begin. The PEGASUS study will address the issue of
DVT/PE prophylaxis in high-risk abdominal surgery,
comparing dalteparin with pentasaccharide. The data
related to the MATISSE DVT and the MATISSE PE
studies, both of them done in patients with established
DVT and PE and randomized to pentasaccaride or
enoxaparin, is close to being released.

Adjudicated

Odds reduction (%)

Pentasaccharide
n/N (%)

Enoxaparin
n/N (%)

Pentasaccharide/
enoxaparin

Exact
95%C

Hip fracture

52/626 (8.3)

119/624 (19.1)

-61.6

-73.4;-45

Total hip replacement

85/1695 (5.0)

151/1716 (8.8)

-45.4

-59.0;-27.6

Total knee replacement

45/361 (12.5)

101/363 (27.8)

-63.1

-75.5;-44.8

All types

182/2682 (6.8)

371/2703 (13.7)

-55.3

-63.2;-45.8

Type of surgery

Table V. Results of a meta-analysis comparing pentasaccharide with enoxaparin on incidence of adjudicated VTE.

S88

PHLEBOLYMPHOLOGY 2002

COMBINED DRUG THERAPY IN THE MANAGEMENT
OF THROMBOSIS
Chairpersons: S. KAUL (USA) and A. KAKKAR (UK)
Moderator: D.MOHANTY (India)

Keynote Lecture: Antiphospholipid syndrome
and vascular diseases
R. L. BICK (USA)

A

ntiphospholipid thrombosis syndromes include not
only the lupus anticoagulant and the anticardiolipin
antibodies, but also more recently discovered subgroups of antiphospholipid antibodies (antibodies
against β-2-glycoprotein-I and antibodies to phosphatidylserine, phosphatidylethanolamine, phosphatidylglycerol, phosphatidylinositol, phosphatidylcholine, and anti-annexin-V).
Antiphospholipid syndrome is the most common
acquired blood protein defect associated with either
arterial or venous thrombosis. The anticardiolipin
antibody thrombosis antiphospholipoid syndrome is
much more common than is the lupus anticoagulant
thrombosis antiphospholipoid syndrome, the ratio
being 5 to The common clinical presentation of these
syndromes is:

1. Arterial and venous thrombosis. (DVT-PE more
common).

PHLEBOLYMPHOLOGY 2002

2. Recurrent miscarriage in the 25- to 35-year age
range.

3. Thrombocytopenia.
4. Premature coronary artery disease.
5. Premature cerebrovascular disease (TIAs, small
stroke syndrome,
stroke).

cerebrovascular

thrombotic

6. Retinal arterial and venous occlusive diseases.
These entities are easy to treat, and the speaker
proposed the use of long-term LMWH for this purpose.
In his experience, new episodes of arterial or venous
thrombosis are well-controlled and prevented with the
use of these medications, although some patients get
tired of the daily subcutaneous injections or develop
osteoporosis. In these situations the author has
recently started the long-term use of the antiplatelet
agent clopidogrel, with excellent clinical control.

S89

ACUTE DEEP VEIN THROMBOSIS I
Chairmen: J. EMMERICH (France), P. CARPENTIER (France)

Genetic factors of venous thromoboembolism
and their consequences
J. EMMERICH (France)

T

he incidence of DVT is 1-2/1000 in France, and
100 000 to 120 000 PE occur each year. The mortality
rate of VTE is estimated to be 2%. Main risk factors of
VTE are:
• acquired risk factors: cancer, hormonal treatment,
immobolization, myeloproliferative diseases, etc.
• genetic risk factors: deficiency in antithrombin, protein S, protein C, mutations in factor V or II. Dysfibrinogemia which is rare, and blood group O which is
very common were not discussed in this presentation.
• “mixed” risk factors: increased levels of factor VIII,
XI, or II, hyperhomocysteinemia, presence of anticardiolipin antibodies.
Thrombophilia is defined as a hypercoagulable state
with onset of clinical manifestations usually occurring
before 45 years old, recurrent disease, and positive
familial history of VTE.

1. Deficiencies of AT, PC, or PS
These are found in 0.8% of the general population and
in 1% to 3% of patients with DVT.
These deficiencies have common characteristics: autosomal dominance, incomplete penetrance. Recurrent
episodes of TVE are found in 50% of the patients, but
precipitating conditions are observed in 50% of the
patients. Each family with coagulation inhibitor deficiency has its own private mutation. The deficiency can
be qualitative or quantitative, but it is not correlated
with the risk of DVT.

2. Factor Leiden
F V Leiden is responsible for an acquired resistance to
activated protein C and is due to a mutation in position 506 (arg -> glu). It is found in an average of 5%
of the caucasian population with a single founder effect
(21 to 34 000 years ago), but in 20% of patients with
VTE (1).

S90

3. Prothrombin G20210 A allele
This is found in 1% to 2% of healthy controls, in 6%
of unselected DVT, and in 18% of patients with unexplained thrombophilia.

4. Combined risk factors
Genetic risk factors can be combined (Table VI),
increasing the risk of occurrence of VTE. For example,
the odds ratio for the occurrence of DVT is 3.88 in F II
G20210 A carriers, but this odds ratio is 20 when F II
G20210A is combined with the presence of a factor V
Leiden. Among 398 cases of patients who were
heterozygous for F V leiden, 12.8% were also
heterozygous for F II. Inversely, among 211 patients
heterozygous for F II, 24.2% were also heterozygous
for F V Leiden. This data illustrate that thrombophilia
is a polygenic and multifactorial disease.
Acquired risk factors like oral contraception (OC) may
increase risk of VTE in carriers of genetic coagulation
inhibitor deficiency, but the increased cumulative risk
has to be balanced with the rarity of the disease in the
population. For example, combining OC and the
presence of a factor V Leiden increases to 35 the odds
ratio of TVE occurrence in females, but it represents
28.5 events/10 000 persons/year, which is very low.

5. New risk factors
High levels of F VIII (>150 %) increase the odds ratio
for VTE to 6 and high levels of factor XI or IX, to 2.
Some others risk factors have been identified, such as
Prot C mutation in the promotor region of the gene
confer a low risk. Inversely, some mutations are protective, such as mutation in Prot C TA allele.
Therapeutic consequences of the discovering of VTE
genetic risk factors are still unclear in daily practice.
Recommendations of the French Society of Human
Genetics have been established (Table VII) but further
long term investigations are needed.

PHLEBOLYMPHOLOGY 2002

F V Leiden

F II G20210A

AT deficiency

25%

8%

Prot S deficiency

19%

2%

Prot C deficiency

38%

10%

Healthy controls

3%

1-2%

Table VI. Frequency of combined genetic risk factors in patients with DVT and healthy controls.

Evaluation of VTE risk

Genetic deficiency or mutation

VTE odds ratio

Low-risk patients
(no long-term
anticoagulation required)

Heterozygous for F II
Heterozygous for FV Leiden
Heterozygous for Prot C or S deficiency

3-5
5-10
5-10

Intermediate risk
(not enough data available,
every case considered
individually)

AT deficiency heterozygous
F V Leiden combined with another abnormality

10-40
10-40

High risk
(long-term anticoagulation
required)

F V Leiden homozygous
Prot C or S deficiency homozygous
AT deficiency homozygous

50-80
>100
lethal

Table VII. Recommendations of the French Society of Human genetics.

Reference
1. Emmerich J et al. Thromb Haemost. 2001;86:809-816.

PHLEBOLYMPHOLOGY 2002

S91

Strategies for the diagnosis of acute venous thromboembolism
A. PERRIER (Switzerland)

S

uspected acute venous thromboembolism (VTE) is a
challenging clinical problem. The aim of the strategies
of the diagnosis of acute VTE is to identify patients at
low risk of having VTE to leave them safely untreated.
None of the diagnosis instruments are ideal (Table VIII)
and they must be combined in a rational and costeffective algorithm, to avoid non-useful invasive
instruments ie, pulmonary angiography or phlebography, which are costly, invasive, and ill-suited. These
stategies have to be evaluated according to management outcome and cost-effectiveness studies, where all
patients are managed according to a predefined diagnosis algorithm. Patients without VTE are not treated
and the safety of these strategies is assessed by 3-month

follow-up of nontreated patients. Clinical VTE assessment has become highly standardized and expressed
as a score which has to be included in strategy algorithms.1 Low clinical score is 0 and was associated with
3% DVT; intermediate score is between 1 and 2 and
was associated with 17% DVT, high score is ≥3 and was
associated with 75% DVT.
The speaker’s team have published strategies for DVT
or PE diagnosis, which have been validated in prospective management studies (Figures 4 and 5). The helical
CT scan may further replace V/Q scan or pulmonary
angiography, only in combination with ultrasonography and clinical assessments.

Clinical probability of DVT assessment  

Low or intermediate

High  

ELISA D Dimer

Venous lower limb US

> 500 µg/L

No DVT

Venography

No DVT 

DVT   

No DVT

DVT   

Venous
lower limb US

No DVT    

< 500 µg/L

DVT

Figure 4. Strategy of DVT diagnosis (US = ultrasonography).

S92

PHLEBOLYMPHOLOGY 2002

Clinical probability of DVT assessment  

Low

Intermediate  

ELISA D Dimer

ELISA D Dimer

> 500 µg/L    

< 500 µg/L

< 500 µg/L

> 500 µg/L  

Proximal compression
US

Proximal compression
US    

No
DVT

DVT

No
DVT

No
DVT    

V/Q Scan

Treatment

V/Q Scan

No
treatment      

Positive

Negative

Non
diagnostive

Non
diagnostive

Negative

Positive      

Treatment

No
treatment

No
treatment

Pulmonary
angiography

No
treatment

Treatment

Figure 5. Strategy of PE diagnosis (US = ultrasonography).

PHLEBOLYMPHOLOGY 2002

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Clinical probability of DVT assessment 

High 

Proximal compression US
duplex  

Positive

Negative 

V/Q Scan   

Negative

Positive   

Figure 5 (continued).

No
diagnostique

Pulmonary
angiography

No
treatment

Treatment

DVT

Venography
Lower-limb venous US
Serial compression US
Plasma D Dimers by ELISA
Plasma D Dimers by whole blood agglutination

PE

Pulmonary angiography
D Dimers by ELISA
D Dimers by whole blood agglutination
Lower-limb venous US
V/Q lung scan
normal
non diagnostic
high probability
Helical CT pulmonary scan (single slice)

Sensitivity

Specificity

97
97
99
99
86

98
98
98
40
65

97
99
85
30-50
99


70

98
40
65
98


90
90

Table VIII. Sensitivity and specificity of the diagnosis instruments.
Reference
1. Wells PS, Anderson DR, Bormanis J, et al. Lancet. 1997;350:1795-1798.

S94

PHLEBOLYMPHOLOGY 2002

Acute treatment of venous thromboembolism
G. MEYER (France)

Low-molecular-weight heparin (LMWH) is an efficient treatment of TVE and may be safer in terms of
bleeding than unfractionated heparin (UFH). LMWH
is given at curative dosage, once or twice a day, without any biological monitoring except for platelet count.
LMWH is maintained for at least 5 days, and warfarin
is started on the first day. Many studies have compared
the different therapeutic strategies:

1. UFH versus LMWH in DVT
No differences were statistically significant between
these 2 regimens concerning recurrent VTE, major or
minor bleeding, but deaths were significantly lower in
LMWH than in the UFH group.1

2. UFH versus LMWH in PE
In the “Thésée study,”2 612 patients with symptomatic
PE were treated either with tinzaparin or UFH. No
significant difference was observed between the
2 groups.
When LMWH at home was compared with UFH at
hospital in 400 patients, no difference was observed
between the 2 groups for major bleeding and recurrent
VTE. In a recent observational study, 108/158 patients
with PE were treated as outpatients; 81 of them were
exclusively treated at home. No readmission in hospital was necessary for these outpatients during a
3-month follow-up. These preliminary data suggest

that some patients with PE can also be treated at home.
In the future, strategy algorithms may occur, including
clinical assessment of the risk of recurrence or bleeding during anticoagulant treatment for VTE (Table IX).
This assessment may identify patients with high risk of
bad outcomes, who may not be treated as outpatients.3

3. Treatment of massive PE
In one small study, massive PE was treated either with
heparin alone or heparin + streptokinase. The study
was rapidly stopped because of 4/4 deaths in the
heparin group versus 0/4 in the thrombolytic treatment group. Pulmonary embolism with shock is a
definitive indication of thrombolytic therapy. The benefit of thrombolysis in clinically stable patients with
hypokinesis or right ventricular dilatation on echocardiography has to be evaluated in clinical trials.

4. Vena cava interruption in PE
In one study, patients with proximal DVT were treated
with anticoagulants, either with vena cava interruption or not. Presence of the filter was significantly associated with a lower recurrence of PE at 1 year. No difference was observed for deaths. DVT significantly
increased in the filter group than in the other group by
the end of the follow-up period. So the role of vena
cava interruption in PE, although life-saving, has its
drawbacks.

Clinical data

Scoring

Cancer

+2

Heart failure

+1

Previous VTE

+1

SBP <100 mm Hg

+2

Pa O2 <8 kPA

+1

Associated DVT

+1

Low risk (0-2): event rate = 2.2% - High risk (≥3): event rate = 27.3%.

Table IX. Geneva adverse outcome score in VTE.
References
1. Dolovitch LR, Ginsberg JS, Douketis JD, Holbrook AM, Cheah G. Arch Intern Med. 2000;160:181-188.
2. Simoneau G, Sors H, Charbonnier B, et al. N Engl J Med. 1997;337:663-669.
3. Wicki J, Perrier A, Perneger TV, Bounaneaux H, Junod AF. Thromb Haemost. 2000;84:548-552.

PHLEBOLYMPHOLOGY 2002

S95

Duration of treatment after deep vein thrombosis
S. SCHULMAN (Sweden)

M

any studies from 1972 to 2001 focused on the duration of anticoagulant treatment after DVT. Recurrence
rates after 12 months of follow-up varied between 7%
and 14% for 3 to 6 weeks of treatment after DVT versus 4% to 15% for 3 to 6 months of treatment, 8 to
27% for 3 months and 9% to 16% for 6 to 12 months
of treatment. Results are difficult to compare because
of differences in methodology. Six months of treatment
appears to be better than 6 weeks, but 3 months may
be valuable. In secondary prevention of VTE, recurrence rates during the first year after interuption of
prolonged treatment is around 10%, whatever the
duration of the initial treatment (6, 12, or 27 months).
A recent meta-analysis1 demonstrated that long duration (6 months) of treatment is better than short duration, without an increased risk of bleeding (relative risk
of bleeding of 1.43). In the Cochrane review, only 4 trials were selected. The risk of recurrence was reduced
with prolonged treatment, without any rebound
phenomon after anticoagulant withdrawal, but an
increased risk of bleeding was observed. Mortality did
not correlate with duration of the treatment (6 weeks,
versus 6 months), in a 10-year follow-up.
Longer treatment may not be better for all, as Pinede
demonstrated that 6 weeks of treatment were enough

for distal DVT, with a risk of recurrence of 1%/year
during the 6-year follow-up. Patients with idiopathic
distal DVT, proximal DVT, or with associated PE have
a higher risk of recurrence (estimated to 4% /year) and
need at least 6 months of treatment.
In conclusion:
• for the majority, up to 6 months of treatment is optimal;
• 6 months of treatment seems better for the risk of
recurrent VTE and perhaps for the risk of cancer;
• 6 months of treatment does not increase bleeding or
mortality;
• for distal DVT, 6 weeks of treatment seems enough;
• longer treatment is required in the presence of active
cancer, ipsilateral recurrence or significant thrombophilia (antithrombin, protein C or S deficiencies,
homozygosity for F V Leiden, presence of anticardiolipin antibodies and combination of defects).

Reference
1. Pinede L. J Int Med. 2000;247:553-562.

Keynote lecture: Quality management in venous
thromboembolism
P. CARPENTIER (France)

Morbidity and mortality related to DVT remained
high despite substantial progress in thromboprophylaxis. In a survey study in a surgery department, only
33% of 2000 patients with high VTE risk had prophylaxis. Quality control at the institution level is based on:

1. One day cross-sectional study in the institution
(prophylaxis applied, systematic venous US examination, risk factor evaluation);

2. Recommendations and education in the hospital;
3. Evaluation of the results by comparative survey of
the practices.
For example, an algorithm for PE diagnosis was etablished

S96

in Grenoble (Figure 5) and validated in a management
study. The study avoided excessive D-Dimer dosages
and decreased the number of performed V/Q scans.
Other quality management approach was an educational program of patients treated with oral anticoagulants. The program was a short 15-minute face-toface discussion between a patient and a nurse or a
doctor. The preliminary evaluation was performed
between 30 educated patients and 30 matched nonrandomized controls. Adequate INR was found in 93% of
educated patients versus 78% in noneducated, and
knowledge testing was adequate in 50% of the patients
before education and in 92% 3 months after education.

PHLEBOLYMPHOLOGY 2002

NEWER CONCEPTS IN THROMBOGENESIS
Chairmen: S. MOUSA (USA), U. CORNELLI (Italy)

Effect of LMWH and different heparin molecular weight fractions
on aggrecanase activity: structure-function relationships
S. A. MOUSA (USA), R. LIU (USA)

Aggreganase is an enzyme which has been identified
in cartilage and is largely responsible for cartilage
aggregan breakdown. Aggreganase is involved in
inflammatory disorders. By inhibiting its activity, the
extracellular barrier is protected, which may reduce
inflammatory disorders or invasion potential of cancers. This study demonstrates that LMWH, with weight
between 3 000 and 12 000 daltons, exibits a concen-

tration dependent inhibitor effect of aggreganase
activity. The inhibitor effect on aggreganase activity is
higher when molecular weight of heparin is high.
These data suggest that the aggreganase inhibitory
effect may be a possible mechanism of LMWH antiinflammatory properties, depending on their molecular weight distribution.

Reversal of the inhibitory efficacy of heparin on endothelial
cell tube formation induced by FGF2 or TF/VIIa by anti-TFPI
S. A. MOUSA, S. MOHAMED, P. RASSMUSEN (USA)

T

inzaparin exibits a concentration dependent
inhibitor effect on angiogenesis. Tissue factor pathway
inhibitor (TFPI), which is increased in plasma by
LMWH, has an antiangiogenic effect in FGF2-induced
angiogenesis in an animal model. This in vitro study
demonstrates that one of the first steps of angiogenesis (endothelial cell tube formation) can be induced by

PHLEBOLYMPHOLOGY 2002

FGF2 or TF/VIIa. LMWH tinzaparin or TFPI can inhibit
this induced angiogenic effect. Anti TFPI, in contrast
with anti-Xa, can reverse the inhibitory effect on
angiogenesis, induced by TFPI or tinzaparin. So, the
antiangiogenic effect of LMWH tinzaparin is mediated
via TFPI but not via its anti-Xa activity.

S97

THROMBOSIS/HEMOSTASIS THERAPEUTIC ADVANCES
Chairmen: R. L. BICK (USA), W. RAAKE (USA)

Bilateral deep vein thrombosies of the calf are not
of minor importance
C. SEINTURIER, J. L. BOSSON, M. COLONNA, P. H. CARPENTIER (France)

T

his study demonstrates that bilateral deep vein
thromboses of the calf (C-DVT) have a poor prognosis,
and have similar outcomes to those of proximal vein
thrombosis. From 1993 to 1998, DVT ± PE was documented in 1913 consecutive patients. Patients with
only PE, without any detectable DVT were not
included. Distal DVT was defined as venous thromboDVT location

sis which was distal to the popliteal vein. DVT diagnosis was assessed by compression ultrasonography (US),
and PE by V/Q scan or spiral CT. Mean patient age was
69 years old, 43% of them were male, 26% outpatients, 33% patients from surgery departments, 22%
with a known cancer. Data from US, V/Q scan, and
spiral CT are in Table X.

Nb of patients

Association with PE (%)

Proximal unilateral

862 (45%)

397 (46 %)

Distal unilateral

783 (41%)

230 (29%)

Proximal bilateral

156 (8%)

83 (53%)

Distal bilateral

112 (6%)

50 (45%)

Table X. Patient assessment data.

Clinical symptoms, cancer prevalence and in/outpatient ratio were not statistically different between bilateral calf DVT group and other DVT.

ing the 2 years’ follow-up was significantly higher in
the bilateral calf DVT group (13%) than in the unilateral calf DVT group (P=0.006).

Survival curves showed that bilateral calf DVT had the
worst prognosis (40% of deaths during the 2 years’ follow-up) and distal unilateral DVT the best (20% of
deaths; P<0.0001). Recurrence was significantly more
frequent in bilateral calf DVT (15% at 2 years) than in
unilateral calf DVT. The risk of cancer occurrence dur-

In patients with bilateral calf DVT, pulmonary
embolism is as frequent as in patients with unilateral
proximal DVT. In addition, patients with bilateral calf
DVT are worse off than patients with proximal DVT in
terms of recurrence, death and occult cancers.

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PHLEBOLYMPHOLOGY 2002

NEW DATA ON DIAGNOSIS, PREVENTION,
AND TREATMENT OF DEEP VEIN THROMBOSIS
Moderator: H. K. BREDDIN (Germany)

Venous thromboembolism and fractured neck of femur
K. HITOS, J. P. FLETCHER (Australia)

The aim of this retrospective study was to assess,
between 1996 and 2000, the clinical incidence of
venous thromboembolism (VTE) and thromboprophylactic protocols in patients presenting to the emergency
department of the Westmead Hospital (Sydney) with
fractured neck of femur. They analyzed 900 patients,
with a predominance of elderly female (median age
82 years) that was operated on in 26% with spinal
anaesthesia. The number of patients receiving no
prophylaxis decreased from 16% in 1996 to 2% in

1999, with an increase of 6% in 2000. This rise in the
last year of the study was explained by some doubts by
some orthopedic surgeons regarding the use of
pharmacologic prophylaxis in patients with spinal
anesthesia. The incidence of clinical VTE also decreased
(not significantly) in the same proportion as the use of
prophylaxis (2% -1996; 0.6%-1999; 1.3%-2000).
They conclude that although the incidence of VTE in
this type of surgery was low, the application of thromboprophylatic protocols should be reviewed regularly.

Deep vein thrombosis in elderly rehabilitation patients:
prevalence, risk factors, and prevention
M. A. SEVESTRE, J. L. BOSSON, J. LABARERE, L. BEYESSIER, P. LEROUX AND THE APAH GROUP (France)

T

he authors conducted a multicenter cross-sectional
study with the purpose of analyzing the cases of deep
venous thrombosis (DVT) in 36 Rehabilitation Departments in France.
They studied 852 patients with duplex ultrasound and
detected 135 DVT (15.8%) with proximal involvement
in 5.9%, and calf vein thrombosis in 10%; 20.9% of
the patients had three or more risk factors of DVT, other
than age.

PHLEBOLYMPHOLOGY 2002

For patients who did not receive prophylaxis, the rate
of DVT was increased when they were immobilized for
less than 30 days, had a history of previous thromboembolism, or had had a hemiplegic stroke. For
patients who received prophylaxis (mechanic/pharmacologic), the rate of DVT remained high among
immobilized patients. In the two groups of patients, a
high incidence of asymptomatic DVT (75%) was
shown. The authors concluded that the prevalence of
DVT in this hospitalized population was high despite
the wide use of prophylaxis, and that immobilization
was the principal risk factor.

S99

Objective end points in clinical trials in patients with acute DVT
H. K. BREDDIN, V. V. KAKKAR, Z. ZDKIOLA, M. SCULLY, R. NAKOV, F. MISSELWITZ (Germany/UK)

The purpose of this study was to compare low-molecular-weight heparin (LMWH) and unfractionated
heparin (UFH ) in the treatment of acute deep venous
thrombosis. Phlebography had been performed and a
Marder score had been determined at baseline and
after 21 days of treatment.

Marder Score
Iliac vein

6

C Fem V

4

S Fem V

10

PO V

4

LLV

16

They used the patients from the CORTES study, and
defined as responders those with 30% or more reduction of the phlebographic index. LMWH significantly
increased the responder rate in comparison with UFH.
Independent of the treatment, the responder group
had significantly different baseline criteria as compared
with non responders (eg, higher Marder score at
baseline, a thromboembolism history and established
cancer), and also higher levels of fibrinogen and of TAT
(thrombin/antithrombin III) complex.
The authors concluded that the use of objective
methods can help to determine at baseline and during
the treatment which patients are at low risk (responder) and high-risk (nonresponder) of a new thromboembolic event. Drug-trial effects could be better
evaluated using this type of protocol. They suggest
further defining well-established protocols similar to
this one for compression sonography.

EXTENDED AIR TRAVEL AND DEEP VEIN THROMBOSIS
Chairmen: B. EKLOF (USA), G. BELCARO (Italy)
With the participation of: P. Haas (Germany), O. Iqbal (USA), H. Partsch (Austria),
J. P. Fletcher (Australia)

Homans gave the first report of travel thrombosis in
5 patients in 1954. In recent years this topic has gained
more public knowledge and was brought to global
attention after the death of a 28-year-old woman due
to pulmonary embolism after a long-haul flight from
Sydney to London.
Factors leading to an increased risk for DVT include
immobilization causing a decreased venous flow velocity, a hypercoagulable state caused by a fluid shift to
the extravascular space, and possible dehydration due
to alcohol consumption and low humidity especially in
airplanes. While in Australia and Hawaii air travel is
the most frequent cause for travel DVT, bus travel is
more frequently the cause in central Europe.

S100

Although there are number of studies published on
travel DVT, the real incidence remains disputed. Frequencies of between 0.001% and 10% of travelers suffering DVT have been published, and there is ongoing
debate over this subject.
Recommendations of a WHO consensus document
stated that there was insufficient data to recommend
specific propylaxis except leg exercise; indiscriminate
use of pharmacologic agents could not be recommended in view of possible side effects.
Three prospective, randomized studies are being
planned on the incidence of DVT and possible preventive measures useful in reducing the risk of travel-associated DVT.

PHLEBOLYMPHOLOGY 2002

Part 11

VASCULAR SURGERY

VASCULAR ACCESS
Moderators: S. STERIOFF (USA), E. ASCHER (USA)

An all-autologous policy for vascular access
A. HINGORANI (USA), E. ASCHER (USA)

It is known that over 300 000 patients are on dialysis
in the US, which costs $16 billion/year for renal
dialysis (public and private) There is a 10% increase
every year suggested to be caused by arteriovenous
grafts (AVGs).
The National Kidney Foundation-Dialysis Outcome
and Quality Initiative (NKF-DOQI),
After a detailed and structured review of 3325 articles
by more than 70 professionals over 2 years it was concluded that:
• Native arteriovenous fistulae (AVF) have the best
4- to 5-year patency rates and require the least interventions to maintain patency.

Based on DOQI – Guidelines, the authors presented the
conclusions of two prospective studies:
• Native AVF have the best 4- to 5-year patency rates
and require the fewest interventions to maintain
patency.
• Less than 30% of the new AV access procedures were
AV fistulae.
• A large percentage of hospitalizations for renal dialysis are due to AVG access failure.
• DOQI guidelines are sound and can be improved
upon with the liberal use of duplex vein mapping.
• An all-autogenous policy is safe and cost-effective for
hemodialysis access.

• Less than 30% of the new AV access procedures were
AV fistulae.

• An all-autogenous policy renders fewer complications and reintervention rates when compared with AV
grafts.

• A large percentage of hospitalizations for renal dialysis are due to AVG access failure.

• Early referral of patients with chronic renal failure
will diminish the need for permanent catheters.

Cell source and cell kinetics in venous stenoses caused
by polytetrafluoroethylene (PTFE) hemodialysis grafts
in experiments
S. MISRA (USA)

P

TFE grafts were placed in 9 castrated juvenile pigs
from either the right or left iliac artery to the ipsilateral
iliac vein. Stenosis formed reproducibly at the venous
anastomosis. The cell origin and migration was determined by performing 5-Bromo-2-deoxyuridine
immunostaining on different days. Cell proliferation
was determined by performing PCNA immunostaining

S102

at the same time points. Conclusions: The source of
early proliferating cells leading to the formation of
venous stenoses was the adventitia. Proliferation and
migration were greatest within the first 2 weeks after
graft placement. These results indicated that the
adventitia may be a therapeutic target for limiting
venous stenosis formation.
PHLEBOLYMPHOLOGY 2002

Results of a multicenter study comparing vascular clip (VCS)
and suture anastomosis for hemodialysis access
A. MILLER, S. SHENOY, W. KIRSCH, F. PETERSEN, C. DICKSON, P. KIM, T. KONKIN (USA)

In this retrospective study patency data for 1385 vascular accesses (clipped or sutured) was extracted from
17 different hospitals and dialysis centers. Five hundred and eighteen arteriovenous fistulae (242 clip, 276
suture) and 827 arteriovenous grafts (443 clip, 384
suture) qualified for patency comparisons.Access
patencies (primary, secondary,overall and intention to
treat) were significantly improved in anastomoses con-

structed with clips. Replacing conventional sutures
with clips significantly reduces the morbidity and cost
associated with maintaining permanent hemodialysis
vascular access patency. This beneficial effect may be due
to the biologic superiority of the staple sutures which
do not go through the lumen, and suggests that the use
of the clips in other cardiovascular surgeries can have
similar benefits on long-term vascular graft patency.

Multicenter evaluation of a polyurethaneurea (PVAG)
vascular access graft as compared with the ePTFE vascular
access graft in hemodialysis: performance of graft with
surgical intervention versus percutaneous method
M. H. GLICKMAN, G. K. STOKES, J. R. ROSS, E. D. SCHUMAN, W. C. STERNBERGH, J. S. LINDBERG,
S. M. MONEY, M. R. LORBER (USA)

In the following multicenter, randomized, prospective
and controlled study the authors compared the performance of a multilayered self-sealing PVAG vascular access graft and expanded ePTFE vascular access
graft in hemodialysis applications in a total of 142
patients. Performance measures included graft survival, complications, time to early cannulation, hemostasis times after decannulation, and performance of

PVAG graft by either surgical intervention or percutaneous intervention.The PVAG graft allows for early
access without compromising long- term performance.
Both PVAG and ePTFE grafts have similar long- term
outcomes, despite early access with the PVAG vascular access grafts. The PVAG graftpewrforms well with
percutaneous interventions and appears to allow for
greater secondary patency rates beyond 600 days.

Treatment of angioaccess-induced hand ischemia by the distal
revascularization-interval ligation (DRIL) procedure:
a prospective analysis of 15 cases
C. SESSA, O. PICHOT, J. MAURIZI-BALZAN, S. PENILLON, M. PECHER, P. PALACIN, M. MAGHLAOUA,
F. KUENTZ, J. L. MAGNE, H. GUIDICELLI (Italy)

S

evere hand ischemia related to arteriovenous fistula
(AVF) for hemodialysis is an uncommon complication
that can lead to irreversible nerve damage and digital
gangrene. The authors report their experience with the
DRIL procedure that comprises: (1) an arterial bypass
with a proximal anastomosis 5 to 7 cm proximal to the
AVF and a distal anastomosis immediately below the
AVF; (2) a ligation of the artery distal to the AVF. The

PHLEBOLYMPHOLOGY 2002

DRIL is the most appropriate technique to deal with
the complex hemodynamic pathophysiology of hand
ischemia caused by AVF. The DRIL restores antegrade
flow to the hand, eliminates reversal of flow, and
maintains functional dialysis access. Patients with
severe hand ischemia induced by the steal syndrome
should be offered the DRIL procedure before considering ligation of the angioaccess.

S103

Multicenter evaluation of a polyurethaneurea (PVAG)
vascular access graft as compared with the ePTFE vascular
access graft in hemodialysis: performance of graft with
surgical intervention versus percutaneous method
M. H. GLICKMAN, G. K. STOKES, J. R. ROSS, E. D. SCHUMAN, W. C. STERNBERGH, J. S. LINDBERG,
S. M. MONEY, M. R. LORBER (USA)

In the following multicenter, randomized, prospective, controlled study the authors compared the performance of a multilayered self-sealing PVAG vascular
access graft and expanded ePTFE vascular access graft
survival, complications, time to early cannulation,
hemostasis times after decannulation, and performance of PVAG graft by either surgical intervention or

percutaneous intervention. The PVAG graft allows for
early access without compromising long-term performance. Both PVAG and ePTFE grafts have similar longterm outcomes, despite early access with the PVAG vascular access grafts. The PVAG graft performs well with
percutaneous interventions and appears to allow for
greater secondary patency rates beyond 600 days.

ENDOVASCULAR AND SURGICAL TREATMENT
OF LOWER-EXTREMITY ISCHEMIA
Moderators: John PANNETON (USA) and Hiroshi SHIGEMATSU (Japan)

Challenges of peripheral endovascular therapy in Egyptian
and North African patients
E. HUSSEIN (Egypt)

The author presented his experience in the use of
endovascular techniques in the treatment of PAOD. He
emphasized the need for individualized options and
the possibility of further endovascular treatment in the

S104

majority of endovascular complications. From his
point of view it was very important to treat patients in
the operating room, in case there was a need for
conversion to surgery.

PHLEBOLYMPHOLOGY 2002

Combined endovascular and open surgical treatment
for lower-extremity occlusive arterial disease
K. CALLIGARO (USA)

Endovascular treatment of inflow or runoff lesions at
the same time as an open procedure has been a matter of debate. There are professionals who prefer to
perform it in two stages in order to diminish possible
complications, and with the idea of obtaining better
permeability. This group from Philadelphia states that
the combination of endovascular and open repair in
arterial disease can lower costs, treat possible complications immediately, and make the endovascular
procedure easier. They perform combined procedures
only when lesions have been detected on duplex or
previous angiogram. In this paper they present their

experience in 125 cases (90 native arteries and
35 grafts) having a mortality rate less than 1% and an
immediate technical success of 91% (114/125). The
11 endovascular failures could be treated at the same
operation. The acute graft or arterial thromboses (during the first postoperative month) were due to the
endovascular procedure in 2% of total of cases; longterm failures (3 years postoperatively) in 6% of total
cases. These facts lead the author to conclude that
concomitant endovascular and open repair of lower
limb revascularization is safe and effective.

Does carbon improve performance of PTFE bypass material?
X. KAPFER, F. M. GROEGLER, W. MEICHELBOECK (Germany)

A

prospective randomized multicenter study was
performed to evaluate the function of a carbonimpregnated PTFE graft versus a standard PTFE
prosthesis. In 17 vascular centers 254 patients were
randomized: 128 received carbon and 126 standard. In
all cases an extranatomic femoroanterior tibial graft
with a distal vein cuff was performed. Thirty-one percent of patients died within the observation period, and
amputation was performed in 27% of carbon- and
32% of standard- treated patients. The life table analy-

PHLEBOLYMPHOLOGY 2002

sis of primary and secondary patency shows similar
results in the first 12 months and turns out to be
statistically better at 12 to 24 months. After 3-year
follow-up there are no differences between the two
groups of patients. The author concluded by pointing
out that reoperations in the carbon group are more
often successful. What surprised the audience was that
the differences, despite the lower thrombogenicity of
the carbon-impregnated graft, appeared after the first
year and not closer to the operative period.

S105

Early results of the Distaflo randomized trial for critical
limb ischemia
J. PANNETON (USA)

A

fter explaining the concept of anastomotic engineering the author presented the early results of the
North American Prospective Randomized Multicenter
Trial comparing Distaflo ePTFE graft with a standard
ePTFE graft with vein cuff for infragenicular revascularization in patients with critical limb ischemia. A total

of 91 bypasses were performed in 89 patients (47
Distaflo/ 44 standard PTFE with vein cuff). In 53% the
bypass was a redo; the distal anastomosis was
performed to below-knee popliteal artery in 21% and
infrapoplitial arteries in 79%. The results were as
follows:

Distaflo

PTFE+vein cuff

Primary patency (30 days)

87% (39/45)

91% (40/44)

Limb salvage (30 days)

96% (43/45)

100% (44/44)

FU 10 months (1-24)

57% (25/44)

59% (26/44)

Table X. Patient assessment data.
As seen, there are no statistically significant differences
between the two techniques during this period of time.
These early clinical results using the Distaflo were
worse than expected according to the in vitro hemo-

dynamic analysis of anastomosis. At any rate, in cases
where the saphenous vein is not available, the Distaflo
is an option which provides technical advantages to
PTFE with cuff.

Infrainguinal revascularization without arteriography:
the Italian experience
F. SPINELLI (Italy)

F

rom 1986 to 2001 this group from Sicily performed
802 distal bypasses in 745 patients. In all cases a Duplex
exam was performed to indicate the feasibility of
surgery; 227 cases (28%) underwent preoperative
angiography while the rest 575 (72%) were submitted
to surgical reconstruction considering the duplex exam
results alone. The author compared the site of distal
anastomosis, operative mortality, early graft occlusion,

S106

major amputations and long-term results between the
two groups. Apart from the fact that in the duplex
group a major number of pedal bypasses are performed, there are no statistically significant differences
between the two analyzed groups. The author
concluded by emphasizing that infrainguinal revascularization is possible based solely on a noninvasive
examination.

PHLEBOLYMPHOLOGY 2002

Infrainguinal revascularization with duplex arteriography:
the Maimonides experience
E. ASCHER (USA)

T

he practice of Duplex arteriography is cheap, noninvasive, mobile, studies the wall morphology, is
hemodynamic and is sensitive to low flows. There are
problems when the runoff is very poor, or there has
been previous surgery, severe calcification, or obesity.
Based on these principles the author presented his
experience in 450 patients, 70 of whom had to be
studied by arteriography due to poor visualization. He
carried out an analysis from aorta to pedal arteries

according to a long (60±20 minutes) or short (25±5
minutes) protocol. The application of one or the other
depends on the clinical stage of the patient (claudication or critical limb ischemia) and the results of femoral
artery examination (triphasic wave=short protocol and
biphasic or monophasic wave=long protocol). This
technique permits a hemodynamic study as well as an
anatomic one detecting calcification or unsuspected
aneurysms.

Challenges of inframalleolar revascularizations:
long-term results with pedal bypass
T. C. BOWER (USA)

The results of 280 pedal bypass graftings for critical
limb ischemia, performed in 256 patients, are analyzed
in this paper. The majority of patients were diabetic and
1/5 had end-stage renal disease. Over half of the
operated limbs required additional interventions to
maintain graft patency or limb salvage (19 early postoperative period and 138 during FU). At 5 years the

PHLEBOLYMPHOLOGY 2002

primary, secondary, and limb salvage rates were 58%,
71%, and 78% respectively. Overall survival at 5 years
was 60%; this was adversely affected by older age at
time of initial operation, the need for amputation, and
the presence of renal failure. Renal failure and the use
of composite grafts predicted limb loss.

S107

AORTIC SURGERY:
CHALLENGES AND INFECTIOUS COMPLICATIONS
Moderators: E. A. BASTOUNIS (Greece) and P. FIORANI (Italy)

Inflammatory abdominal aortic aneurysms:
new data on pathogenesis and management
P. FIORANI (Italy)

Inflammatory abdominal aortic aneurysms (IAAA)
are a rare entity of unclear pathogenesis characterized
by dense perianeurysmal fibrosis involving the adjacent organs. Preoperative detection permits choosing
the best surgical approach and avoid possible ureteric
injury. During his presentation P. Fiorani presented his
experience over the last 20 years in which his group

has operated on 92 IAAA (6.3% of total AAA). In their
experience the left retroperitoneal approach is the
most anatomically advantageous route in order to prevent iatrogenic lesions of adjacent structures as ureters.
Endovascular treatment in this condition seems to
have a weaker action in improving retroperitoneal
fibrosis, and therefore is not indicated.

Combined abdominal aortic aneurysmectomy
and other abdominal operations
E. A. BASTOUNIS (Greece)

T

he management of an AAA and coexisting abdominal diseases has been a long-standing controversy. It is
not as clear to whether a single or two-stage approach
is the appropriate treatment option and which lesion
should be treated first. The author has presented his
experience in concomitant operation performed in
47 patients. As a second operation he differentiates
minor operations (cholecystectomy, inguinal hernia
repair, or small-bowel resection) and major operations
(colon, gastric, renal, or hepatic resection). The

S108

combination with major operation resulted in a considerable prolongation of operative time and blood
loss. At any rate he stated that combination of aneurysmectomy with other abdominal operations can be
achieved with low morbidity and mortality rates
depending on the high standards of care. In the future,
the application of endovascular options in vascular
surgery and laparoscopic approach in general surgery
may bring new light to the controversy.

PHLEBOLYMPHOLOGY 2002

A 10-year experience of surgery for aortoiliac occlusive disease
M. M. FETT, H. C. SMITH, D. S. BYRNE, A. J. MCKAY, R. O. QUIN, P. N. ROGERS (UK)

T

he report of a 20% mortality rate after aortic surgery
for occlusive disease by the Scottish Audit of Surgical
Mortality in 1998, provoked the revision over the last
10 years of this approach in the Gartnavel General
Hospital. The data from this unit suggest that the
National Health Service has significantly underestimated the number of aortic surgical procedures being
carried out in Scotland, presenting a mortality rate

which is misleadingly high. The mortality rate of
aortobifemoral bypass in occlusive arterial disease has
been 3.5%, but when applied to claudicant patients it
is lowered to 0.8%. During the last 10 years the
number of patients treated by means of aortobifemoral
bypass has remained nearly constant, and an increase
in endovascular procedures has been noted.

Infected aortic aneurysms: in situ reconstruction is a safe
and durable option
G. S. ODERICH, J. M. PANNETON, T. C. BOWER, K. J. CHERRY, C. M. ROWLAND, A. A. NOEL,
J. W. HALLET, P. GLOVICZKI (USA)

T

he clinical data, and early and late outcomes in 43
patients treated for infected aortic aneurysms over a
25-year period (1976-2000) were reviewed. There
were infrarenal in only 40% of cases. Fifty-three percent were in ruptured aneurysms. Operative mortality
was 21%. Mean follow-up was 4.3 years. Cumulative
survival at 1 and 5 years was 82% and 50% respectively. Variables associated with increased risk of

aneurysm-related death included adjacent organ infection, female gender, Staphilococcus aureus infection,
aneurysm rupture, and location other the infrarenal
aorta. However, late outcome is favorable with no
aneurysm-related death and low graft-related complication rate similar to standard repair. In situ aortic
grafting is a safe and durable option in most patients.

Aortic reconstruction in infected fields: early results of the
United States Cryopreserved Aortic Allograft (USCAA) Registry
A. A. NOEL, P. GLOVICZKI, K. J. CHERRY, JR, H. SAFI, J. GOLDSTONE, M. D. MORASCH,
K. H. JOHANSEN (Members of the USCAA Registry, USA)

A

ortic reconstructions from primary graft infection,
micotic aneurysm, and aortic graft-enteric erosion bear
high mortality and morbidity and current treatment
options are not ideal. As cryopreserved aortic allografts
(CAA) have been successfully implanted in infected
fields they are supposed to be suitable for aortic
reconstructions. The early results (mean follow-up
5.3 months) of 56 implants inserted from March 1999

PHLEBOLYMPHOLOGY 2002

to August 2000 were presented. It was observed that
in situ replacement with CAA in infected fields carries
a high mortality (13% 30-day mortality and overall
mortality of 30%), but most deaths are not due to
allograft failure but to multiorgan failure. Late graftrelated complications such as reinfection, thrombosis,
or aneurysmal changes are unknown.

S109

NEW TECHNOLOGY FOR MINIMALLY INVASIVE
VASCULAR RECONSTRUCTIONS
Moderator: F. MAHLER (Switzerland)
Whit the participation of: U. Frank (Germany), S. Gale (USA), F. Mahler (Switzerland),
and M.K. Sheehan (USA)

The presence of chronic venous insufficiency due to
deep venous incompetence represents one of the more
difficult problems in the vascular field. Among the different solutions proposed over time, none have been
shown to be reliable.
The group from the Jobst Vascular Center in Ohio presented the initial experience with a percutaneous valve
bioprosthesis: the VenPro. The prosthesis, obtained
from cows, is inserted via the jugular vein and is
implanted at the level of the superficial femoral vein.
The results are preliminary, and at present time no conclusions can be obtained from this study.
The application of brachitherapy (Iridium 192 irradiation at 12 Greys at 3 mm depth) in order to diminish
the percentage of myointimal hyperplasia after dilatation of arterial lesions at the femoropopliteal level has
showed conflicting results. F. Mahler presented his
group’s experience using brachiotherapy in 100
patients referred to percutaneous transluminal angioplasty (PTA), for relapsing of stenosis after an initial
PTA in the femoropopliteal segment. The results
showed no beneficial effects in the group with bra-

S110

chiotherapy and PTA related to a control group of PTA
only, with frequent occurrence of thrombotic occlusions in stented arteries.
The group from the Loyola University, USA, presented
data that clearly demonstrate the increased number of
endovascular procedures compared with the decreased
trend in the number of surgical operations preformed
in the last 10 years at his institution. Dr Sheehan
pointed out the need for the acquisition of endovascular skills by the vascular surgeons.
The treatment of long superficial femoral artery (SFA)
occlusions by means of endovascular catheter-based
technologies was also reviewed by U. Frank. In the last
5 years his group has treated around 400 patients,
mean age 67 years, with an average occlusion length
of 16.6 cm in the SFA. He reported a primary success
rate of 90%, with less than 1% of severe complications.
In the first year of follow-up the rate of restenosis was
33%, which limits the intermediate and long-term success of this procedure and makes frequent reinterventions inevitable.

PHLEBOLYMPHOLOGY 2002

Part 12

VASCULAR DISEASES

RENOVASCULAR HYPERTENSION
Moderators: R. CAMBRIA (USA) and M. McKUSICK (USA)

Diagnosis and management of acute thromboembolism:
past, present, and future
V. V. KAKKAR (UK)
Introduced by J. FAREED (USA)

V.V. Kakkar stated that venous thromboembolism
is more aggressive and resistant to therapy in cancer
patients. It has been shown, that DVT prophylaxis during chemotherapy prolongs survival. A meta-analysis
of 3581 patients with venous thromboembolic events

showed a 40% reduction in 3-month mortality with
LMWH in comparison with unfractionated heparin. A
prospective trial on DVT prophlaxis in advanced solid
tumor malignancy (dalteparin vs placebo) is ongoing.

Renal artery stent placement: clinical outcomes
and complications
M. McKUSICK (USA)

The author analyzed retrospectively 140 patients
(June 1996-October 2000) undergoing renal artery
balloon angioplasty and stent placement for atherosclerotic disease. He evaluated the patients’ comorbidities, lesion locations, serum creatinine, blood pressure, and procedure-related complications during a
mean follow-up of 8.3 months.
All patients had at least 50% stenosis, and 54.9% had
70% to 90%. The technical success of the procedure
was 98%, and pre-existing hypertension improved in
68% of the patients, but only 2.2% of them were
cured. The creatinine improved in 17.2% was

S112

unchanged in 62.5%, and worsened in 20.3% of the
patients treated. There were 7.5% major complications
(without need for of surgical resolution) that included
artery rupture (2%) aortic dissection (1.4%), flow-limiting renal artery dissection (1.4%), thrombus/embolus in the renal artery (1.4%), puncture site pseudoaneurysm (0.7%), and vein thrombosis in 0.7% of the
cases. Death 30 days after the procedure occurred in
1.4% of patients.
The author concluded that renal artery ostial stenosis
can be treated successfully with this method, making
the surgical intervention unnecessary.

PHLEBOLYMPHOLOGY 2002

Surgical treatment of renal artery disease;
current indications and results
R. CAMBRIA

T

he author presented his experience in the surgical
treatment of renal artery stenosis, which involved
approximately 500 reconstructions over a period of 20
years. He emphasized that the combination of aortic
with renal problems has now become more common
than in the earlier years of his practice, and that the
mortality has been lowered to 1% to 2%.
Surgical procedures should be tailored to the patient,
and nonanatomic renal bypass (hepatic a. / renal a.)
could provide equivalent functional long-term patency
rates (82% patency at 5 years) to that expected with
aortorenal bypass (87% patency rate).

The author prefers transaortic endarterectomy with
simultaneous aortic reconstruction in cases of bilateral
renal artery ostial lesions. In 80% of the patients, there
is improvement in blood pressure.
Finally he emphasized that the global evaluation of the
patient and the risk/benefit of this kind of intervention
are most important, because in their series about 40%
of the patients had died in 5 years from coronary heart
disease.

The natural history of renal artery stenosis and medical
treatment of renovascular hypertension
S. TEXTOR

In the USA population, there are probably 600 000
patients with renovascular hypertension, of which
85% has an of atherosclerosis cause, 14% from fibromuscular disease, and about 1% of other causes. A
great percentage of patients do not have a clear
diagnosis and treatment. Renal atherosclerosis is a
manifestation of a global disease, and many of these
patients have involvement of coronary (20%) and
peripheral vascular (40%) arteries.
Understanding the natural history and knowing that
medical therapy can reduce significantly the cardiovascular risks are fundamental to management. Which
factors can indicate the progression of the disease are
not well defined, but the cases with less severe stenosis at baseline have a slower progression. Recent
studies during medical therapy of “incidental” stenosis

PHLEBOLYMPHOLOGY 2002

indicate that clinical progression requiring intervention occurs in less than 10% to 15% over 4 to 5 years.
Medical therapy (angiotensin-converting enzyme
inhibitors – ACEI, and angiotensin receptor blockersARBs) is a primary element of the treatment of the
renal artery stenosis, and can produce a successful
blood pressure control in a considerable number of
cases.
It is very important to know that there are recognizable syndromes which herald failure of medical therapy,
and the need to consider renal revascularization such
as intractable hypertension, progressive renal failure
during medical therapy, and “flash “ pulmonary edema
out of proportion to cardiac dysfunction. Only in those
cases where there is evident failure of medical therapy
is revascularization justified.

S113

VASOSPASM, INFLAMMATION, AND INFECTION
IN VASCULAR DISEASE
Moderator: R. SHEPHERD (USA)

Currrent management of Raynaud’s syndrome: an overview
R. SHEPHERD (USA)

Definition of Raynaud’s syndrome: an exaggerated
contractile response of the muscles of digital arteries to
cold (starting with pallor, followed by cyanosis and
ending with reactive hyperemia).
Prevalence: 4.3% of population in the USA, 19% of the
population in the UK, female:male ratio of 4:1
Onset: second to fourth decade.
Potential mechanisms: (a) increased sympathetic
nerve activity (b) endothelial cell dysfunction
Classifications: (a) primary Raynaud’s (b) secondary
Raynaud’s (eg, repetitive local trauma).

Vascular laboratory findings:
• Can only “confirm” the principally clinical diagnosis
• Primary or secondary?
• Ice immersion test followed by evaluation of laser
Doppler blood flow with hot box (laser Doppler thermal challenge)
• Angiographic studies cannot show evident obstruction or alteration of blood flow of the extremities, but
some anatomical features have been observed.
Specific therapy of primary Raynaud’s:
• Mild symptoms: heat conservation, no medication
• Severe symptoms: vasodilatator (calcium channel
antagonist, α-blocker, direct vasodilator, ACE
inhibitor): 50% to 70% respond to medication

Digital necrosis of the upper limb: a retrospective study
of 278 cases
U. MICHON-PASTUREL, V. DELCEY, N. CAILLEUX, E. HACHULLA, P. Y. HATRON, B. DEVULDER,
H. COURTOIS, H. LEVESQUE (France)

Digital necrosis of the upper limb (DNUL) is less frequent than gangrene in the lower limbs (ratio 1/4).
The causes are much more various, and atheroma is
rarely involved. A retrospective study including 278
cases of DNUL observed in the medical centers of Lille
and Rouen was reported. Evaluation of the patients
included clinical examination, evaluation of vascular
risks, biological tests, nailfold capillary examination,
and duplex ultrasonography.
Etiologic diagnosis was found in 96% of patients and
remained unknown in 4%.
An overview was given of the different etiology:
• Connective tissue disease (>> systemic slerosis, >>
women): 32.6%

S114

• Professional arteriopathies (Hammer syndrome,
vibration syndrome): 15%
• Buerger disease (>>men): 10%
• Emboli: 8.6%
• Hematologic disorders (cryoprotein, myeoloproliferative disorders, thrombophilia): 7.8%)
• Vasculitis: 4.3%
• Miscellaneous diseases: 4%
• Smoking: 6.5%
In nearly 50% of the patients, digital necrosis was multifactorial. Tobacco was the most frequent associated cofactor (55%). The clinical outcome is very acceptable with
complete healing in 81% and amputation in 16% of cases
(strong correlation between amputation and infection).

PHLEBOLYMPHOLOGY 2002

VASCULAR MALFORMATIONS
Moderator: R. SHEPHERD (USA)

Vestigial marginal vein: surgical treatment of 56 cases
J. F. CORMIER, F. CORMIER, J. M. FICHELLE (France)

The vestial marginal vein (VMV) is the most frequent
etiology in congenital varicose veins, and these authors
present 56 cases that they followed between 19852001. Klippel-Trenaunay syndrome was present in
31 cases with a Malan-Servelle syndrome in 3 cases. In
16 cases there was no overgrowth of the affected limb.
In 6 cases there were arteriovenous shunts (Parkes –
Weber Syndrome). The indications for surgery were
severe functional symptomatology in 10 patients and
complications (bleeding, thrombophlebitis, ulcers,
overgrowth of the limb) in 39 cases. All cases were classified using Vollmar’s classification of the end of the
marginal vein. In type I, there were 12 cases (end of

popliteal vein) in type II, 18 cases (superficial or deep
femoral vein) in type III, 12 cases (common femoral
vein), and type IV, 14 cases (internal iliac vein). Only
in two cases the VMV has a vicarious role iliofemoral
aplasia. In the other cases the duplex scan showed deep
venous system incompetence in 15 cases and hypoplasia in 13 cases. Surgical treatment was performed
among 38 patients and consisted in stripping or in segmentar resection of the VMV with perforant ligature,
followed by coil embolization or sclerotherapy of residual veins. They concluded that in any case there was
no worsening of the situation but the prognosis
depends on the associated malformation.

Keynote address: Multidiciplinary management
of vascular malformations
B. B. LEE (South Korea)

C

ongenital vascular malformations (CVM) remain
one of the major challenges to meet, because treatment
leads to substantial risk of morbidity and recurrence.
The authors give great importance to the anatomic and
physiologic classification of the CVM, and proposed the
Hamburg Classification (Table I).
An interdisciplinary consultation allows proper application of the various treatment modalities, including
embolosclerotherapy and surgical therapy. Two
hundred and six patients experienced emboloscleType

rotherapy using a various combination of absolute
ethanol, contour particles, coils, OK-432, and N-butyl
cyanoacrylate (NBCA), and had a total of 504 sessions.
The immediate success rate of ethanol and/or NBCA
after each session was 95.5% in 155 patients.
A multidisciplinary treatment strategy for management of CVMs can improve overall treatment success
with a reduced morbidity and recurrence compared
with conventional approaches.

Truncular form

Extratruncular form

Predominant arterial defects

Aplasia or obstructive
Dilatation

Infiltrating
Limited

Predominant venous defects

Aplasia or obstrutive
Dilatation

Infiltrating
Limited

Predominant lymphatic defects

Aplasia or obstructive
Dilatation

Infiltrating
Limited

Predominant arteriovenous defects

Superficial

Infiltrating
Limited

Combined mixed vascular defects
(without A-V shunts)

Arterial and venous without A-V shunt
Hemolymphatic, with and without A-V shunt

Infiltrating
Limit

Table I. Hamburg classification.
PHLEBOLYMPHOLOGY 2002

S115

INDEX

A
Agnell G
Aguiar E
Aleksandrovics V
Ambrozy E
Andreadis E
Andreozzi G
Andrews K
Angelides N
Arko F
Ascher E

S88
S24 – S51
S47
S47
S66
S15 – S68
S66
S34
S58 – S60
S102 – S10
B

Baker W
Bakhos M
Balas P
Bastounis E
Bauer K
Baumeister R
Baumeister R
Beatty P
Beebe H
Belcaro G
Belch J
Bender C
Bergan J
Berridge D
Beyessier L
Biasi G
Bick R
Bjarnason H
Blättler W
Blinc A
Böhler K
Bosson J
Bower T
Breddin H
Brokelmann J
Buller H
Bullo C
Bürgelin K
Burnand K
Buth J
Byrne D
Byrne P

S13 – S36
S86
S22
S36 – S108
S88
S62
S63
S68
S26
S12 – S100
S54 – S71
S63
S16 – S44
S70
S99
S38
S89 – S98
S19
S77
S87
S47
S98 – S99
S35 - S107 – S109
S85 – S99 - S100
S49
S88
S38
S19 – S20
S43 – S62
S29
S109
S20
C

Cailleux N
Calligaro K
Callini E
Cambria R
Campisi C
Carpentier P
Carra G
Cherry K
Chetter I
Clement D
Coleridge Smith P
Colonna M
Conrad J
Cormier F
Cormier J
Cornelli U
Corson
Coughlin P
Courtois H
Criado F

S114
S105
S25
S112 – S113
S62 – S63
S90 – S96 – S98
S38
S34 - S35 - S109
S70
S12 – S55 – S73 – S88
S18
S98
S59
S35 – S115
S35 – S115
S86 – S97
S18
S20 – S70
S114
S27
D

D'Angelo F
Daud A
De Castro Silva M
Delcey V

S118

S25
S86
S50 – S51
S114

Deriu G
Deschamps C
Devulder B
Diamantopoulos M
Dickson C
Dion Y
Dormandy J
Durand A

S34
S63
S114
S66
S103
S24
S71
S62

J
Jacobson J
Jaff M
S73
Jiang P
S46
Jöckel K
Johansen K
Johnson B

S16

S45
S109
S58 – S60
K

E
Ehringer H
Eklof B
Elalamy I
Emmerich J
Enrici E
Eriksson B

S47
S100
S59
S90
S50
S88
F

Fareed J
Farjallat M
Feldo M
Fernandes E
Fernandes J
Fett M
Fichelle J
Fillinger M
Fillis K
Fiorani P
Fletcher J
Flügel P
Frank U

S80 – S86 –S112
S51
S20
S39
S39
S109
S35 – S115
S23
S58 – S60
S108
S45 –S46 – S99 – S100
S19 – S20
S19 S20 – S110
G

Gaggl U
S47
Gale S
S110
Gerdsen R
S46
Gerlach H
S77
Giannakopoulos N
S66
Glasz T
S16
Glickman M
S103 – S104
Gloviczki P
S12 – S14 –S15 – S22 – S26
S35 – S45 – S54 – S63 – S109
Goldhaber S
S80 – S83
Goldstone J
S109
Greenberg R
S26
Groegler F
S105
Gschwandtner M
S47
Guidicelli H
S103
H
Haas S
Hachulla E
Hallet J
Harris E
Hatron P
Heinz G
Hiatt W
Hingorani A
Hirsch A
Hirsh A
Hitos K
Hobson R
Hofer J
Hollier L
Hoppensteadt D
Horellou M
Horn B
Housely E
Hull R
Hussein E

S79 – S82 – S84 – S100
S114
S109
S58 – S60
S114
S47
S54 – S71
S102
S71
S73
S99
S35
S35
S14
S81 – S86
S59
S19 – S20
S73
S13 – S32 - S82
S104
I

Iqbal O
Irvine J

S86 – S100
S32

Kadar A
Kaiser B
Kakkar V
Kakou M
Kalman
Kalra M
Kamionek I
Kapfer X
Kaul S
Kent P
Kesik J
Kester R
Kirsch W
Klokocovnik T
Konkin T
Kovalovs S
Krievins D
Kucharzewski M
Kuentz F

S16
S81
S78 – S89 – S100 – S112
S66
S22 – S23
S35
S48
S105
S89
S20 – S70
S20
S20 – S70
S103
S24
S103
S47
S47
S48
S103
L

Labarere J
Labs K
Lacis A
Le Chatelier A
Lederle F
Lederman A
Lee B
Leroux P
Levesque H
Lietuvietis E
Lindberg J
Liu R
Lorber M
Lusiani L

S99
S72
S47
S59
S20
S24 – S51
S49 – S115
S99
S114
S47
S103 – S104
S97
S103 – S104
S38
M

Ma Q
Maghlaoua M
Magne J
Mahler F
Maric S
Matsunaga P
Mattasi R
Maurizi-Balzan J
McCollum C
Medn G
Meichelboeck W
Meissner M
Messmore H
Meyer G
Michalak J
Michiels J
Michon –Pasturel U
Mickay A
Miller A
Misra S
Misselwitz F
Mohamed S
Mohanty D
Moneta F
Moneta G
Money S

S86
S103
S103
S110
S47
S24
S25
S103
S18
S47
S105
S12
S86
S95
S20
S76
S114
S109
S103
S102
S100
S97
S89
S72
S43 – S47
S103 – S104

PHLEBOLYMPHOLOGY 2002

Moore W
Morasch M
Morrison N
Mousa S

S27 S 38
S109
S19
S97
N

Nakov R
Neumann F
Nicolaides A
Noel A
Nogales L
Norgren L
Novo S

S100
S19 – S20
S1 – S12 – S36 – S66
S35 – S63 – S109
S84
S54 – S71
S15 – S32 – S37 – S88

R
Raake W
Rabe E
Ramussen T
Rassmusen P
Richardson P
Rieger H
Riles T
Rogers P
Rooke R
Ross J
Rowland C
Rutherford R
S

O
Oderich G
Olcott C
Oldenburg A
Ombandza-Moussa E
Ouriel K

S109
S58 – S60
S23 – S36
S59
S29

P
Pagnan A
S38
Palacin P
S103
Panneton J
S35 – S104 – S106 – S109
Pannier-Fischer F
S45 S46
Papasteriades C
S66
Parodi J
S28 – S39
Partsch H
S42 – S76 – S100
Pastore A
S25
Pavkov M
S49
Pearce W
S22
Pecher M
S103
Penillon S
S103
Perrin M
S42 – S44 – S92
Pesavnto R
S38
Petersen F
S103
Piccolo P
S86
Pichot O
S1 – S58 – S103
Pipinos I
S58 – S60
Ponca C
S46
Poncar C
S45
Q
Quin R

PHLEBOLYMPHOLOGY 2002

S98
S45 – S46
S35
S97
S67
S32 – S68 – S76
S39
N109
S32 – S47 – S62
S103 –S104
S109
S54

S109

Safi H
Samama M
Sasahara A
Schanzer H
Schattenkirchner S
Schneider B
Schonath M
Schreen G
Schulman S
Schultz C
Schuman E
Schwarzwälder U
Scott D
Seinturier C
Selzle K
Sersa I
Sessa C
Sevestre M
Shah D
Shapira A
Sheehan M
Shenov S
Shepherd J
Shepherd R
Shigematsu H
Shimoura J
Simari R
Simkin R
Simonian S
Slezak A

S25 – S109
S59
S80
S44 – S50
S48
S47
S48
S51
S96
S86
S103 – S104
S19 – S20
S70
S98
S48
S87
S103
S99
S37
S50
S110
S103
S17
S104
S84
S17
S50 – S51
S45
S48

Smith H
Spinelli F
Stanson A
Sterioff S
Sternbergh W
Stokes G
Strukelj M
Sulkowski L
Sullivan T

S109
S106
S63
S102
S103 – S104
S103 - S104
S87
S48
S27
T

Tarassi K
Textor S
Thibaut G
Thor S
Tilson D
Tonello

S66
S113
S62
S47
S22
S38
U

Ulloa J

S50 – S51
V

Vaghi M
Vallence P
Vanhoutte P
Vassilopoulos C
Veith F
Visona A

S25
S67
S17
S66
S25 – S28 – S32
S38
W

Walenga J
Wayne Johnston K
Weston M
White R
Willfort A
Wittenhorst M
Woodcock J
Wright D
Wronski J

S84 – S86
S22
S20
S28
S47
S45 S46
S67
S18
S20
Z

Zarins C
Zdkiola Z
Zeller T
Zorzoli C
Zubilewicz T

S22 - S24 – S28 – S58 – S60
S100
S19 – S20
S25
S20

S119

SERVIER RESEARCH
FELLOWSHIP 2003-2005

awarded by the
RESEARCH FUND OF THE
UNION INTERNATIONALE
DE PHLÉBOLOGIE

To be awarded at the next chapter of the UIP
which will be held in San Diego in August 2003,
the SERVIER RESEARCH FELLOWSHIP
will provide a 30 000 USD grant for 2 years’ work
on a research project.
The competition is open to young candidates
who have a specific interest in the field
of phlebolymphology. The project must consist of

original basic or clinical research in an area
of phlebolymphology
The fellowship will be made available from
1st September 2003 and end on 31st July 2005.

DEADLINE FOR SUBMISSION: 28th February, 2003
ENQUIRIES Jean-Jérôme GUEX
AND SUBMISSIONS TO: Fonds de Recherche UIP
32, boulevard Dubouchage
06000 NICE - France
The results of the research will be presented
during the XVth World Congress of the UIP in 2005
in Rio de Janeiro, Brazil, and must be in a form
suitable for publication in an international journal.

S120

PHLEBOLYMPHOLOGY 2002

A leading company in the field of phlebolymphology,
dedicated to increasing knowledge and recognition of venous disease worldwide

Servier International - 22, rue Garnier, 92578 Neuilly sur Seine Cedex - France
Website: http://www.servier.com

03 DN 009 BA

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