Veins

Objectives: P-selectin inhibition has been found to limit venous thrombosis. We hypothesize that elevated levels of P-selectin will amplify thrombosis, mediated by procoagulant microparticles (MPs). Methods: Male mice (Mus musculus, n659), 20 to 25 grams, underwent IVC ligation to induce thrombosis. Groups consisted of wild type (WT) C57BL/6 controls, mice with high circulating levels of soluble P-selectin (^CT), P-selectin gene-interrupted knockout mice (PKO), and E-and P-selectin gene-interrupted mice (EPKO). Additional groups were used to evaluate the ability of a P-sel antagonist (rPSGL-Ig) and an antibody directed against PSGL-1 to downregulate the effects of P-sel in^CT mice and WT mice administered soluble P-sel at time of thrombosis. Animals were sacrificed on days 2 and 6 after IVC ligation. Thrombus mass (TM), vein wall morphometrics, and serum leukocyte/platelet microparticles (MPs) were evaluated by means of double-stained fluorescence-activated cell scanning analysis, and soluble P-and E-sel protein determination by ELISA. Results: At days 2 and 6 in phase I of the experiment, significant differences (P < .01) in TM were noted between groups, with^CT animals having the largest thrombi (50% and 57% increase in TM compared to WT at days 2 and 6) while EPKO mice had the smallest thrombi. Statistically, greater levels of neutrophils and total inflammatory cells were noted in the vein walls of^CT animals at day 2 compared with WT and PKO animals. A significant difference was noted between^CT and EPKO for neutrophils, monocytes, and total inflammatory cells, also at day 2. At day 6, the only statistically significant difference was found for monocytes, with a higher number in the^CT animals than in WT animals. The evaluation of MPs revealed that the^CT mice had a mixed leukocyte (MAC-1) and platelet (CD41) MP population that was also present in WT and PKO mice on day 2 and day 6. EPKO mice revealed a primarily platelet-derived MP population. Of interest, the^CT mice with the highest TM showed a high amount of mean channel fluorescence for MAC-1 (phycoerythrin) antibody, indicative of leukocyte MPs.^CT mice revealed statistically higher levels of soluble P-selectin at days 2 and 6. In phase 2, an antibody directed against PSGL-1 was more effective than rPSGL-Ig in decreasing TM and limiting leukocyte-derived MP fluorescence. Conclusions: This study demonstrates that high circulating levels of P-selectin are associated with increased thrombosis, whereas a lack of P-selectin and E-selectin is associated with a lessening of thrombosis. Additionally, leukocyte MPs are associated with venous thrombus formation. These data suggest the importance of selectins to venous thrombogenesis and show that P-selectin and leukocyte-derived MPs should be good targets to limit venous thrombus formation. (J Vasc Surg 2003;38:1075-89.)

The aim of this study was to determine the extent of accumulation of lipoprotein(a) [Lp(a)] in human arterial wall and to define its potential role in atherogenesis. Biopsies routinely taken from the ascending aorta of 107 patients undergoing aortocoronary bypass surgery were analyzed for lipid and lipoprotein parameters, which were then correlated to serum values. A significant positive correlation was established between serum Lp(a) and arterial wall apolipoprotein (apo)(a) by enzyme-linked immunosorbent assay. High serum Lp(a) also led to a significant increase of apo B in the arterial wall. No significant correlation was found between apo B in serum and aortic tissue. Apo B was found to be partially linked to apo(a) in the aortic extract. Furthermore, apo(a) was found to be intact, as determined by its molecular weight in sodium dodecyl sulfate electrophoresis. This technique also revealed that the apo(a) isoform pattern of aortic homogenate was comparable to the individual seru...

Peripherally inserted central catheters (PICC) are widely used to provide central venous access, often in chronically ill patients with long-term intravenous access requirements. There are a number of significant complications related to both insertion and maintenance of PICC lines, including catheter malposition, migration, venous thrombosis, and line fracture. The incidence of these complications is likely to rise as the number of patients undergoing intravenous outpatient therapy increases, with a corresponding rise in radiologist input. This paper provides an overview of the relevant peripheral and central venous anatomy, including anatomical variations, and outlines the complications of PICC lines. Imaging examples demonstrate the range of radiological findings seen in these complications.

Accumulating data on the human fetal circulation shows the similarity to the experimental animal physiology, but with important differences. The human fetus seems to circulate less blood through the placenta, shunt less through the ductus venosus and foramen ovale, but direct more blood through the lungs than the fetal sheep. However, there are substantial individual variations and the pattern changes with gestational age. The normalised umbilical blood flow decreases with gestational age, and, at 28 to 32 weeks, a new level of development seems to be reached. At this stage, the shunting through the ductus venosus and the foramen ovale reaches a minimum, and the flow through the lungs a maximum. The ductus venosus and foramen ovale are functionally closely related and represent an important distributional unit for the venous return. The left portal branch represents a venous watershed, and, similarly, the isthmus aorta an arterial watershed. Thus, the fetal central circulation is a very flexible and adaptive circulatory system. The responses to increased afterload, hypoxaemia and acidaemia in the human fetus are equivalent to those found in animal studies: increased ductus venosus and foramen ovale shunting, increased impedance in the lungs, reduced impedance in the brain, increasingly reversed flow in the aortic isthmus and a more prominent coronary blood flow.

4-Hydroxynonenal (HNE) is a major aldehydic product formed by peroxidation of omega 6-unsaturated fatty acids and is regarded as a specific marker of lipid peroxidation. In this paper we demonstrate that there is a physiological steady-state concentration of HNE in human venous blood plasma. For the quantitative determination of HNE a modified version of an existing, but tedious and time-consuming HPLC method was developed. The extraction of aldehydic hydrazones from plasma was performed using an Extrelut column and the separation step by thin-layer chromatography was replaced by column chromatography on silica gel. The concentration of HNE in human blood plasma was in the same range as the concentration that was found to inhibit the proliferation of cells of the peripheral tissues, i.e., endothelial cells and fibroblasts in vitro. In an experiment with reduced peripheral blood flow a temporary significant increase of HNE was observed during reperfusion. It was concluded that lipid ...

A robotic system to take blood samples autonomously from the forearm is presented and preliminary results are discussed which demonstrate its feasibility. Force/position profiles, while pressing a flat-headed probe against the surface of the skin, enable the determination of a vein's location to within 1 mm on a phantom. When a needle is inserted, the characteristic force/position profile, on puncturing the vein wall, is distinctive enough to implement automatic needle withdrawal to prevent overshoot. Future developments of the project are presented that provide both an autonomous blood sampling robot and a force-feedback surgical trainer.

The effects of vasoactive agonists on systemic blood vessels were examined with respect to anatomical location and gravity acclimation in the semi-arboreal snake, Elaphe Obsoleta. Major blood vessels were reactive to putative neurotransmitters, hormones or local factors in vessel specific patterns. Catecholamines, adenosine triphosphate, histamine and high potassium (80mM) stimulated significantly greater tension per unit vessel mass in posterior than anterior arteries. Anterior vessels were significantly more sensitive to catecholamines than midbody and posterior vessels. Angiotensin II stimulated significantly greater tension in carotid artery than in midbody and posterior dorsal aorta. Arginine vasotocin strongly contracted the left and right aortic arches and anterior dorsal aorta. Veins were strongly contracted by catecholamines, high potassium and angiotensin II, but less so by adenosine triphosphate, arginine vasotocin and histamine. Precontracted vessels were relaxed by acetylcholine and sodium nitroprusside, but not by atrial natriuretic peptide or bradykinin. Chronic exposure of snakes to intermittent hypergravity stress (+1.5 Gz at tail) did not affect the majority of vessel responses. These data demonstrate that in vitro tension correlates with known patterns of sympathetic innervation and suggest Abbreviations ACH acetylcholine -ADA anterior dorsal aorta" ANG II salmon asnl-valS-angiotensin II' ANP rat ileZ6-atrial natriuretic peptide 9 A TP adenosine triphosphate -A V T arginine vasotocin 9 BK human bradykinin 9 BL total body length 9 CA carotid artery 9 CONT control -ECso effective concentration producing 50% maximal response 9 EPI epinephrine 9 + Gz earth's gravity force 9 HI-G high gravity acclimation 9 HI K + 80 mM high potassium 9 JV jugular vein -LAA left aortic arch -MDA midbody dorsal aorta -MPV midbody portal vein-MS Mackenzie's solution" NEPI norepinephrine; pDz-log ECs0 9 PDA posterior dorsal aorta. PPV posterior portal vein-RAA right aortic arch 9 SNP sodium nitroprusside

Objectives: to compare the amputation rates, quality of life and health care costs in patients receiving duplex ultrasound scanning against clinical surveillance following femoropopliteal and femorocrural vein bypass. Design: multi-centre, prospective, randomised controlled trial. Methods: 1200 patients with a patent vein graft at 30 days postoperatively will be randomised to either clinical or duplex follow-up. All patients are seen in an out-patient clinic at 6 weeks, then 3, 6, 9, 12 and 18 months postoperatively. At each appointment patients are examined clinically; palpable pulses in the graft and crural vessels, presenting symptoms and their ankle-branchial pressure indices (ABPIs) measured. In the duplex group only, the results of the scan are monitored. The incidence of radiological and/or surgical interventions throughout the follow-up period are also noted. Quality of life is measured using the SF-36 and EuroQol questionnaires at the 6 and 18 month appointments. Hospital stays and resource use are documented for health economic analysis. Results: the primary endpoint of this study is amputation or death from vascular causes; however, graft patency rates will also be compared between the groups. Quality of life and health economic data will be used to determine if there is any benefit in either arm in these outcomes between follow-up strategies. Conclusions: this large, randomised-controlled trial will hopefully provide direct evidence on the benefit of duplex surveillance for vein grafts in terms of limb salvage, quality of life of the patients and cost-benefit to the purchaser.

A recent modification of the Kety-Schmidt wash-out technique for ' 33xenon was used to measure whole-brain blood flow (CBF) and oxygen consumption (CMR,,) 1 to 4 hours after termination of halothane anesthesia in 15 Wistar rats. I n this 3-hour experimental period, mean CBF and CMRo, were reduced to 29 and 43% of control values, respectively. CBF and CMR,, determincd at the beginning and end of the experimental period were not significantly different from each other. Cerebral venous O2 tension was significantly higher than in the control group, supporting recent suggestions of a primary, intrinsic effect of halothane on the homeostatic control of this variable. It is concluded that halothane is not useful for cerebral metabolic studies in the rat.

Purpose: Venous reconstructions are rarely performed, and factors affecting long-term results of bypass grafts implanted in the venous system are not well defined. In this report we updated our experience. Methods: The clinical data of all patients who underwent venous reconstruction for iliofemoral or inferior vena caval (IVC) occlusion due to nonmalignant disease between January 1985 and June 1999 were retrospectively reviewed. Patients were classified, and outcomes were compared according to the guidelines of the Joint Vascular Societies. Results: Forty-two patients, 23 males and 19 females (mean age, 40 years; range, 16-81), underwent 44 venous reconstructions. Thirty-six patients had limb swelling or venous claudication, 38 had pain, and 14 had healed or active ulcers. The cause of obstruction was congenital in two and acquired in 40 (deep vein thrombosis, 25; trauma, 5; retroperitoneal fibrosis, 4; IVC occlusion devices, 4; others, 2). Eighteen patients underwent saphenous vein crossover grafts (Palma procedure), 17 had expanded polytetrafluoroethylene (ePTFE) grafts implanted (femorocaval, 8; iliocaval, 5; crossfemoral, 3; cavoatrial, 1), 6 patients had spiral vein grafts (5 iliac/femoral and 1 cavoatrial), and 1 underwent femoral vein patch angioplasty. Clinical follow-up averaged 3.5 years (median, 2.5), and graft follow-up with imaging studies averaged 2.6 years (median, 1.6). Seven patients were lost to follow-up. The secondary 3-year patency rate for all reconstructions was 62%. Palma procedures had a 4-year patency rate of 83%. The secondary patency rate of iliocaval and femorocaval ePTFE bypass grafts at 2 years was 54%. The secondary patency was lower in patients with an arteriovenous fistula (P = .023). All ePTFE grafts had a 45% patency rate at 2 years, not significantly different from saphenous vein grafts (83%, P = .16). Clinical scores improved with graft patency (median, 0.0 vs 1.5; P = .044). Conclusions: Venous reconstructions for iliofemoral or IVC obstruction offer 3-year patency rates of 62%. The Palma procedure with autologous saphenous vein had the best long-term patency, whereas long-term success with ePTFE was moderate. The use of an arteriovenous fistula to improve graft patency remains controversial

Venous compliance declines with age and improves with chronic endurance exercise. KAATSU, an exercise combined with blood flow restriction (BFR), is a unique training method for promoting muscle hypertrophy and strength gains by using low-intensity resistance exercises or walking. This method also induces pooling of venous blood in the legs. Therefore, we hypothesized that slow walking with BFR may affect limb venous compliance and examined the influence of 6 weeks of walking with BFR on venous compliance in older women. Sixteen women aged 59-78 years were partially randomized into either a slow walking with BFR group (n = 9, BFR walk group) or a non-exercising control group (n = 7, control group). The BFR walk group performed 20-min treadmill slow walking (67 m min )1 ), 5 days per week for 6 weeks. Before (pre) and after (post) those 6 weeks, venous properties were assessed using strain gauge venous occlusion plethysmography. After 6 weeks, leg venous compliance increased significantly in the BFR walk group (pre: 0AE0518 ± 0AE0084, post: 0AE0619 ± 0AE0150 ml 100 ml )1 mmHg )1 , P<0AE05), and maximal venous outflow (MVO) at 80 mmHg also increased significantly after the BFR walk group trained for 6 weeks (pre: 55AE3 ± 15AE6, post: 67AE1 ± 18AE9 ml 100 ml )1 min )1 , P<0AE01), but no significant differences were observed in venous compliance and MVO in the control group. In addition, there was no significant change in arm compliance in the BFR walk group. In conclusion, this study provides the first evidence that 6 weeks of walking exercise with BFR may improve limb venous compliance in untrained elder female subjects.

The presacral venous plexus results from anastomoses between the lateral and median sacral veins, and courses into the pelvic fascia covering the anterior aspect of the body of the sacrum. The presacral venous plexus is not directly visible during rectal surgery, and injuries to this plexus may be life-threatening. Dissection of the retrorectal plane or anchoring of the rectum to the sacral promontory as in rectal prolapse surgery exposes the patient to the risk of injury to the presacral venous plexus. The aim of this study was to identify some avascular areas in the anterior aspect of the sacrum in order to lower the occurrence of such injuries during rectal surgery. The pelvis of 10 fresh cadavers was dissected after injection of a colored resin into the inferior vena cava, and the presacral venous plexus was studied. Four avascular tetragonal areas were common to all the specimens. The corners of a square with a side of 3 cm, centered on the anterior aspect of the body of sacrum, were always contained in the avascular areas. The upper side of this square was parallel to a line passing through the sacral promontory, at a 3 cm distance from it. Staples or sutures should be placed in the avascular areas to avoid injuries to the presacral venous plexus.

Fetal bypass presents several perfusion challenges, including the need for high arterial flow rates using flexible arterial and small venous cannulae. We hypothesized that vacuum-assisted venous drainage (VAVD) would improve drainage and allow perfusion at higher flow rates which are thought to prevent placental dysfunction induced by fetal bypass. We conducted bypass for 60 minutes in 14 fetal lambs (90-105 days gestation; ϳ1-1.5 kg) using a roller pump and various angled venous cannulae (8 -12 Fr). VAVD at -20 mm Hg or -40 mm Hg was compared with gravity drainage. Average flow using gravity drainage was 139 ml/kg/min; after VAVD, we achieved average flows of 285 ml/kg/min (range, 109 -481 ml/kg/min). VAVD at -40 mm Hg caused right atrial trauma in four fetuses; no injury was seen at -20 mm Hg. Venous air entrainment during repair of the injuries did not result in any apparent air embolism. Spontaneous pulmonary hemorrhage occurred in two fetuses at the highest flows (> 400 ml/kg/min). In all but one case, termination of bypass was followed by placental dysfunction within 120 minutes. VAVD can be safely applied during fetal bypass provided pressures are kept < -20 mm Hg. However, the achieved higher flow rates do not prevent postbypass placental dysfunction and may indeed be detrimental to the fetus. ASAIO Journal 2005; 51:000-000. From the AQ: 1

Ambulatory phlebectomy is an elegant outpatient procedure for the removal of varicose veins. One of the keys to its success is the ability to perform the procedure under local anesthesia. A new form of anesthesia, tumescent anesthesia, has been developed for liposuction surgery and is now being expanded for use in other surgical disciplines. To determine the efficacy and safety as well as review the use and advantages of tumescent anesthesia in ambulatory phlebectomy. A retrospective review of phlebectomy cases performed in our offices under tumescent anesthesia. The reported level of intraoperative and postoperative pain was very low. The complication rate was consistent with other reports except for a higher number of hematomas (3.4%). Tumescent anesthesia provides a very safe, comfortable method of anesthetizing patients for ambulatory phlebectomy. Epinephrine, in appropriate concentrations, should be a part of all tumescent anesthetic solutions used for phlebectomy as it may decrease the incidence of hematoma.

Balloon-occluded retrograde transvenous obliteration (BRTO) of bleeding gastric varices (GV) is well described in the literature. Using Ethanolamine oleate as the sclerosing agent in BRTO, but it is not readily available in the United States in the desired concentrations. The authors' aim is to describe their initial experience with BRTO using sodium tetradecyl sulfate (STS) foam as an alternative sclerosing agent. Materials and Methods: The authors performed a retrospective review of their initial series in which STS foam was used to treat bleeding GV using BRTO. All study subjects had endoscopic evidence of gastric variceal bleeding. STS foam was made using a combination of agents with a 3:2:1 ratio of gas: 3% STS: Lipiodol (Ethiodol; Savage Laboratories, Melville, New York). Mean values and ranges were calculated for each variable, and clinical and imaging outcomes were assessed. Results: The authors performed BRTO in 22 cirrhotic patients (11 men and 11 women) with a mean age of 52 years (range, 23-83 years). Technical success was achieved in 20 of 22 (91%) patients. Complications occurred in three of 22 (14%) patients. The overall mean dose of STS used was 300 mg (range, 30-600 mg) with mean total volume of sclerosant mixture of 34.1 mL (range, 10-65 mL). Follow-up imaging was available for 18 of 20 (90%) technically successful procedures with a mean period of 89 days (range, 1-359 days). Complete obliteration of GV was achieved in 16 of 18 (89%) patients. There were no cases of recurrent variceal bleeding with a mean clinical follow-up period of 130 days (range, 1-510). Conclusions: BRTO utilizing STS foam appears effective in obliterating bleeding GVs with good short-term outcomes. ABBREVIATIONS BRTO ϭ balloon-occluded retrograde transvenous obliteration, EBC ϭ endoscopic N-butyl-2-cyanoacrylate, EO ϭ ethanolamine oleate, EUS ϭ endoscopic ultrasound, GRS ϭ gastrorenal shunt, GV ϭ gastric varices, STS ϭ sodium tetradecyl sulfate, TIPS ϭ transjugular intrahepatic portosystemic shunts

terms of recurrence rates. However, nowadays surgeon's preference is still the most relevant criteria to choose the technique for varicocele treatment. In this article, we review the use of ASS for varicocele treatment. We also describe our step-by-step technique. Finally, we report the clinical outcomes observed in a large series of consecutive patients treated by the senior author. HISTORY OF ANTEGRADE SCROTAL SCLEROTHERAPY ASS of spermatic veins was described for the first time in 1993 by Tauber and Johnsen. 3 The technique initially described in German language was popularized only after the publication in 1994 of the results of initial 285 patients treated in Hamburg. 4 In our experience, in December 1997 ASS progressively replaced the open and laparoscopic retroperitoneal ligature of spermatic veins. However, after an initial experience using the original technique described by Tauber and Johnsen in 1994, 4 the senior author of this article started to use an original modified technique reporting a high percentage of success and a low percentage of complications in an initial series of 201 consecutive

Neuromuscular electrical stimulation (NMES) may help reduce the incidence of deep vein thrombosis (DVT) in the postoperative total hip and knee arthroplasty patient. However, discomfort associated with stimulus may reduce patient acceptance of NMES as therapy. The aim of this study was to determine if patient comfort and tolerance of NMES was affected by applying stimulation in proximity to an orthopaedic implant. There was a concern that this may cause a concentration of current around the metal which could result in hypersensitivity of NMES and reduce its effectiveness. Twenty patients took part in this study, 10 total hip and 10 total knee arthroplasty patients. Each patient was at least 3 weeks post surgery. NMES was applied to the calf muscles of each leg using skin surface electrodes. Four excitatory levels were recorded, which were: sensory threshold, motor threshold, pain threshold and pain tolerance. Following this, patients underwent a 5 min stimulation session and indicated their overall comfort level on a visual analogue scale. Measurements of peak venous velocity, mean velocity and volume flow were recorded by duplex scanning from the popliteal vein at rest and in response to NMES elicited contractions during this session. Finally, patients completed a short verbal interview detailing their experience with the NMES treatment. The blood flow results showed increases in peak venous velocities, mean velocities and volume flow produced by NMES of 200%, 60% and 60% respectively when compared to resting blood flow. Comfort assessment indicated that the presence of a metallic implant did not give rise to hypersensitivity due to NMES. Patients found the application of calf muscle NMES comfortable and acceptable as a treatment. We conclude that the use of NMES on postoperative orthopaedic patients can be safely administered as a DVT prevention method.

Reviewing the literature on the vascular anatomy of the spinal epidural space, it appeared that the knowledge of the internal vertebral venous plexus is limited. Injection studies of the entire internal vertebral venous plexus after application of modern techniques, to the best of our knowledge, have never been performed. Based on the clinical importance of these structures, it was decided to study the human vertebral venous system after Araldite CY 221 injection, in order to update the morphological characteristics of the internal vertebral venous system.

This paper describes a software system for measuring cross-sectional area in reconstructed elliptical tubular structures. A measurement tool was developed using the freely available, cross-platform, open-source three-dimensional (3-D) Slicer environment. The software is easy to operate and allows the user to make multiple measurements on the fly. Results can be displayed to the screen, output to the system printer, and written to a user-specified data file for later analysis in commercial spreadsheet software. Measuring a known cross-sectional area tested the software. Phantoms of known physical dimensions were imaged using both CT and MR. The measured cross-sectional areas reported by the software were compared to each other, and the cross-sectional areas calculated from the known physical dimensions of the phantoms. The measurement errors were negligible. The results of this study indicate that the cross-sectional area measurement tool described provides reliable measurements and is an inexpensive and versatile alternative to high-end 3-D modeling software. ᭧

Arterial plasma drug concentrations should be a strong predictor of resultant physiological and behavioral effects of smoked drugs. Nine healthy male volunteers, who were current users of smoked and i.v. cocaine, participated in a study directly comparing arterial and venous cocaine plasma concentrations after smoked and i.v. cocaine. Each volunteer was first tested under all dosing conditions without an arterial catheter (phase I), to determine whether subjects could tolerate each cocaine dose, before testing with an arterial catheter (phase II). Phase II consisted of two test days, each consisting of either four smoked-cocaine sessions (sham, 12.5, 25 and 50 mg) or four i.v. cocaine sessions (0, 8, 16 and 32 mg) in ascending order, spaced 90 min apart. For the two highest doses for each route, arterial and venous blood samples were taken simultaneously before drug administration, during drug administration and frequently after drug administration. At the same time, cardiovascular ...

To determine the effect of elastic compression stockings on deep venous hemodynamics we measured ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, amplitude of venous pressure excursion, and duplex-derived common femoral and popliteal vein diameter and peak flow velocities with and without stockings in 10 healthy subjects and 16 patients with chronic deep venous insufficiency. The effects of below-knee and above-knee 30 to 40 torr and 40 to 50 torr gradient stockings were studied. Despite documentation of substantial stocking compressive effects by skin pressure measurements, neither below-knee or above-knee elastic compression stockings significantly improved ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, or the amplitude of venous pressure excursion in healthy patients or in patients with deep venous insufficiency (p > 0.05).

Objectives: To define the normative values of scrotal vein diameters, investigate the eventual presence and characteristics of scrotal reflux in healthy subjects, and describe its implication for the diagnosis of scrotal varicocele. Methods: Color-Doppler ultrasonography was performed on a population of 145 healthy, symptomless subjects, with clinical examinations and semen analyses within normal limits. Results: The upper limit of the scrotal veins diameter (3.7-3.8 mm) exceeds values presently employed for a diagnosis of varicocele. Furthermore, a high percentage of healthy subjects (53%) were found to have reflux in the scrotal veins, currently considered one of the criteria for diagnosing varicocele, especially in its subclinical form. Conclusions: To reduce the risk of misinterpretations between the various specialists involved in Color-Doppler ultrasonography and urologists, quantitative data of the scrotal veins (i.e., maximum diameter and the presence, velocity, and duration of reflux) should be described in reports of sonographic examinations performed for scrotal varicocele.

Objective: Dual antiplatelet therapy with clopidogrel plus acetylsalicylic acid (ASA) is superior to ASA alone in patients with acute coronary syndromes and in those undergoing percutaneous coronary intervention. We sought to determine whether clopidogrel plus ASA conferred benefit on limb outcomes over ASA alone in patients undergoing below-knee bypass grafting. Methods: Patients undergoing unilateral, below-knee bypass graft for atherosclerotic peripheral arterial disease (PAD) were enrolled 2 to 4 days after surgery and were randomly assigned to clopidogrel 75 mg/day plus ASA 75 to 100 mg/day or placebo plus ASA 75 to 100 mg/day for 6 to 24 months. The primary efficacy endpoint was a composite of index-graft occlusion or revascularization, above-ankle amputation of the affected limb, or death. The primary safety endpoint was severe bleeding Global Utilization of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries [GUSTO] classification). Results: In the overall population, the primary endpoint occurred in 149 of 425 patients in the clopidogrel group vs 151 of 426 patients in the placebo (plus ASA) group (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.78-1.23). In a prespecified subgroup analysis, the primary endpoint was significantly reduced by clopidogrel in prosthetic graft patients (HR, 0.65; 95% CI, 0.45-0.95; P ‫؍‬ .025) but not in venous graft patients (HR, 1.25; 95% CI, 0.94-1.67, not significant [NS]). A significant statistical interaction between treatment effect and graft type was observed (P interaction ‫؍‬ .008). Although total bleeds were more frequent with clopidogrel, there was no significant difference between the rates of severe bleeding in the clopidogrel and placebo (plus ASA) groups (2.1% vs 1.2%). Conclusion: The combination of clopidogrel plus ASA did not improve limb or systemic outcomes in the overall population of PAD patients requiring below-knee bypass grafting. Subgroup analysis suggests that clopidogrel plus ASA confers benefit in patients receiving prosthetic grafts without significantly increasing major bleeding risk. ( J Vasc Surg 2010;52:825-33.)

A lateral approach to the popliteal artery Is described. The anatomic limits of the exposure, appropriate technical maneuvers to maximize this exposure, and alternative procedures are discussed. Groin or thigh Infections In patients requiring urgent revascularlzatlon are the most common Indications. However, some traumatic Injuries and certain elective reconstructions are appropriately treated with this technique. The lateral exposure to the popliteal artery Is not technically demanding and offers a useful alternative for treatment of selected vascular problems.

The testis is an important organ upon which the survival of the human species depends. The testicular arteries and veins play major roles in the thermo-regulation that is essential for the efficient functioning of this organ. However, very little is found in the literature about the veins and their anatomical variations. Therefore the testicular veins and arteries in 150 dissection room cadavers at the University of the Witwatersrand, Johannesburg and University of Zimbabwe, Harare were examined for anatomical variations from the usual descriptions in textbooks of Anatomy. Variations were found more frequently in the testicular veins than in the accompanying arteries. The variations, which were more common on the left side, were seen in 32 (21.3%) of the cadavers. In 6 (18.8%) of these cases, the variations were present bilaterally. The veins were either completely or partially duplicated, with or without beading. The duplicated veins terminated in the corresponding renal veins either separately or after combining into one vein. In two cases, the right testicular vein terminated in the right renal vein, rather than in the inferior vena cava. Anatomical variations of the testicular artery were present in 4.7% of cases and were associated with their origin, which were either from unusually high levels of the abdominal aorta or from the renal artery.

Tumor vascular permeability factor (VPF) was initially identified by Senger et al. in the laboratory of Dvorak [1] and was later confirmed as identical to VEGF [2, 3, 4 and 5]. Although more attention has been focused on angiogenesis, the other side of biological activity of VEGF, the ...

The purpose of this anatomic cadaveric study was to determine with trocars in situ the relationships of 12 shoulder arthroscopic portals frequently used with the adjacent musculotendinous and neurovascular structures. Methods: Twelve shoulders of embalmed cadavers installed in a beach-chair position were dissected. Twelve different portals were established by using their authors' description: posterior "soft point," central posterior, anterior central, anterior inferior, anterior superior, 5 o'clock portal, Neviaser, superolateral, transrotator cuff approach, Port of Wilmington, anterolateral, and posterolateral. Six of these portals were placed on each shoulder so that each portal was studied 6 times. Dissections were conduced with trocars in situ to take into account their volume. The distance to the adjacent relevant neurovascular structures at risk (axillar and suprascapular nerves, axillar and suprascapular arteries, and cephalic vein) were measured, arm at side, by using a calliper. Musculotendinous structures crossed by portals were noticed. Results: The cephalic vein was injured twice by anterior portals. The 5 o'clock portal is at most risk of neurovascular injury. It is located at mean distances to the axillar artery and nerve of 13 and 15 mm, respectively. Other anterior, posterior, superior, and lateral portals are safe with mean distances higher than 20 mm. No musculotendinous rupture nor large injury occurred. Conclusions: The present study shows that the trocars placement of the studied portals did not create, except for the cephalic vein, any lesion of the neurovascular adjacent structures. Clinical Relevance: This study suggests, except for the 5 o'clock portal, the safety of the shoulder arthroscopic portals tested regarding to the neurovascular adjacent structures.

Avulsion injury to portal vein tributaries can result in worrying haemorrhage during pancreatic gastric, and colonic resection. Attempts to control these avulsion injuries can result in extension of the tear into major portal vein tributaries. Pressure on the bleeding point tends to extend the laceration towards the portal vein, which bleeds torrentially when pressure is released for suturing. A technique is described to control the bleeding from these portal vein tributaries. This technique relies on adequate visualization and control of the torn ends of the portal vein tributaries thus enabling the surgeon to precisely suture the disrupted vessel without any collateral damage. This technique has been used on a number of occasions over the last decade with excellent results.

Abbreviations: APTT ϭ activated partial thromboplastin time; DVT ϭ deep venous thrombosis; HIT ϭ heparin-induced thrombocytopenia; INR ϭ international normalized ratio; IPG ϭ impedance plethysmography; LMW ϭ low molecular weight; PE ϭ pulmonary embolism; PTE ϭ pulmonary thromboendarterectomy; TCT ϭ thrombin clotting time; tPA ϭ tissue plasminogen activator (alteplase); VTE ϭ venous thromboembolism (CHEST 2001; 119:176S-193S)

In mice, intravenous injections are commonly administered in the lateral tail vein. This technique is sometimes difficult to carry out and may cause stress to mice. Though injection through the retro-orbital venous sinus can provide certain advantages over lateral tail vein injection, this method is poorly defined and infrequently used. To compare the efficacy of these two routes of drug delivery, the authors injected MAFIA transgenic mice with the depletion agent AP20187, which selectively induces apoptosis in macrophages. Each mouse received five consecutive daily injections through either the lateral tail vein or the retro-orbital venous sinus. The authors then compared macrophage depletion in different tissues (lung, spleen, bone marrow and peritoneal exudate cells). Both routes of injection were similarly effective. A separate experiment using BALB/c mice indicated that retro-orbital venous sinus injection was the less stressful of the two methods.