INTRODUCTIONThe pattern of venous reflux in Thai patients with chronic venous insufficiency (CVI) was studied in correlation with clinical manifestations.

METHODSUltrasonography findings and clinical data were prospectively collected and retrospectively reviewed.

RESULTSCVI was found in 104 legs of 79 patients (mean age 59.8 ± 12.5 years; C4: 24.1%, C5: 8.9%, C6: 67.1%). 6.7% of the legs had a history of deep vein thrombosis (DVT). The prevalence of superficial vein reflux (SVR), deep vein reflux (DVR), and combined SVR and DVR in 90 legs without previous venous surgery was 82.2%, 63.3% and 57.8%, respectively. In legs with SVR, the prevalence of great saphenous vein reflux (GSVR), small saphenous vein reflux (SSVR), and combined GSVR and SSVR was 91.9%, 33.8% and 25.7%, respectively. 77.0% of SVR involved the calf segment. For medial ulceration, 79.6% had GSVR and 35.2% had SSVR. For lateral ulceration, 46.7% had SSVR and 33.3% had isolated GSVR. Pulsatile venous signal was found in 3.3% of legs. In 17 legs with ulceration after previous surgical treatment, calf vein reflux (residual calf great saphenous vein or small saphenous vein) was found in 13 (76.5%) legs.

CONCLUSIONCalf vein reflux plays an important role in CVI and in patients with recurrent ulceration after previous superficial venous surgery. Although GSVR was present in most patients with CVI in the legs, SSVR may present in one-third of patients, especially those with lateral ulceration. The high prevalence of DVR in the absence of DVT and the presence of a pulsatile venous signal in some patients highlight the incomplete understanding of CVI aetiology.

Adult ; Aged ; Aged, 80 and over ; Body Mass Index ; Chronic Disease ; Female ; Humans ; Leg ; blood supply ; pathology ; Male ; Middle Aged ; Prevalence ; Retrospective Studies ; Saphenous Vein ; diagnostic imaging ; Severity of Illness Index ; Thailand ; Ultrasonography ; Vascular Surgical Procedures ; Venous Insufficiency ; diagnostic imaging ; Venous Thrombosis ; diagnostic imaging

OBJECTIVEThis study aims to investigate the relationship between major signal points (MaSPs) of the lower extremities used in court-type Thai traditional massage (CTTM) and the corresponding underlying anatomical structures, as well as to determine the short-term changes in blood flow and skin temperature of volunteers experiencing CTTM.

METHODSMaSPs were identified and marked on cadavers before acrylic color was injected. The underlying structures marked with acrylic colors were observed and the anatomical structures were determined. Then, pressure was applied to each MaSP in human volunteers (lateral side of leg and medial side of leg) and blood flow on right dorsalis pedis artery was measured using duplex ultrasound while skin temperature changes were monitored using an infrared themographic camera.

RESULTSShort-term changes in the blood flow parameters, volume flow and average velocity, compared to baseline (P < 0.05), were observed on MaSP of the lower extremity, ML4. Changes in the peak systolic velocity of the area ML5 were also observed relative to baseline. The skin temperature of two different MaSPs on the lateral side of leg (LL4 and LL5) and four on the medial side of leg (ML2, ML3, ML4 and ML5) was significantly increased (P < 0.05) at 1 min after pressure application.

CONCLUSIONThis study established the clear correlation between the location of MaSP, as defined in CTTM, and the underlying anatomical structures. The effect of massage can stimulate skin blood flow because results showed increased skin temperature and blood flow characteristics. While these results were statistically significant, they may not be clinically relevant, as the present study focused on the immediate physiological effect of manipulation, rather than treatment effects. Thus, this study will serve as baseline data for further clinical studies in CTTM.

Adolescent ; Adult ; Female ; Humans ; Leg ; blood supply ; Male ; Massage ; methods ; Skin Temperature ; Thailand

Objective To evaluate the feasibility of peripheral artery CT angiography (CTA)under 70 kV with 50 ml contrast medium on the third-generation dual-source CT. Methods Totally 82 patients who were equally randomized into two groups:70 kV group:the scan was performed under 70 kV tube voltage+50 ml iopromide on the third-generation dual-source CT;and 100 kV group:the scan was performed under 100 kV tube voltage+90 ml iopromide on the second-generation dual-source CT. The CT number of abdominal aorta,bilateral common iliac arteries,common femoral arteries,superficial femoral arteries,popliteal arteries and arteries of the calf were measured and contrast to noise ratio(CNR),signal to noise ratio(SNR)were calculated. The image quality was compared between these two groups. Results The dose-length product was (195.8±46.9)mGy·cm in 70 kV group,which was significantly lower than that in 100 kV group (461.6±57.9)mGy·cm,and was decreased by 57% (t=-22.848,P=0.000). Compared with the 100 kV group,the CT number of the proximal abdominal aorta in 70 kV group was significantly lower(t=-2.502,P=0.014),while the CT number of superficial femoral arteries (t=3.053,P=0.003)and popliteal arteries (t=4.013,P=0.000)was much higher in 70 kV group. SNR and CNR of proximal abdominal aorta,distal abdominal aorta,bilateral common iliac arteries,common femoral arteries,superficial femoral arteries,popliteal arteries and arteries of the calf were significantly lower in 70 kV group than those in 100 kV group (all P<0.05). The artifacts in abdominal aorta (t=2.893,P=0.000)and feet arteries (t=3.776,P=0.000)were higher in 70 kV group than those in 100 kV group,the enhancement of abdominal aorta (t=-1.000,P=0.002)and feet arteries (t=2.893,P=0.010)were lower in 70 kV group,the enhancement of femoral-popliteal arteries (t=-1.000,P=0.000)and arteries of calf (t=4.261,P=0.000)were higher in 70 kV group. Compared with the 100 kV group,the image noise in aorta (t=2.048,P=0.044),femoral-popliteal arteries (t=8.370,P=0.000),arteries of the calf (t=8.315,P=0.000)and feet arteries (t=7.202,P=0.000)were higher in 70 kV group. Conclusion Compared to conventional scan protocol,using 70 kV tube voltage with 50 ml contrast medium to perform peripheral artery CTA can assure the image quality and meanwhile remarkably reduce the radiation dose and the use of contrast medium.
Aorta, Abdominal ; diagnostic imaging ; Arteries ; diagnostic imaging ; Artifacts ; Computed Tomography Angiography ; Contrast Media ; Humans ; Iohexol ; analogs & derivatives ; Leg ; blood supply ; Radiation Dosage ; Signal-To-Noise Ratio ; Tomography, X-Ray Computed

OBJECTIVETo investigate the clinical effect of anastomosis of superficial veins for improving the drainage of perforator propeller flaps.

METHODSFrom Sept. 2011 to Dec. 2012, 11 cases with soft tissue defects and chronic ulcer wound at extremities were treated with adjacent perforator propeller flaps, which were pedicled by the peroneal artery(5 cases), or the lateral supramalleolar artery(3 cases), or the ulnar artery (2 cases), or the posterior interrosseous artery (1 case). The wound size ranged from from 3.0 cm x 2. 5 cm to 11. 0 cm x 4. 0 cm, and the falps size ranged from 6 cm x 3 cm to 21 em x 5 cm. One superficial vein in all the flaps was anastomosed with superficial vein in the recipient area. The blood supply of the flaps were recorded after operation 1 - 3 months after operation, the fluency of anastomosed vein was detected by color Doppler ultrasound. Flap swelling evaluations were performed in early 3 months and later 3 - 6 months, and the results were classified into 4 grading degrees. 6 months later, Questionnaire of the flap aesthetic satisfactory was performed for seven patients during follow-up period.

RESULTS9 flaps survived completely, two flaps had partial marginal skin necrosis in the distal end, which were both managed with surgical debridement, and both wounds healed in two months. 9 cases were followed up for more than 12 - 19 months. The early rsults of flap swelling evaluations were: I degree 0 case, II degree 8 cases, III degree 3 cases, IV degree 0 case, and the later results were: I degree 7 cases, II degree 4 cases, III degree 0 case, IV degree 0 case. The flaps had ideal appearance, good contour, and high aesthetic satisfactory (100%). The mean flap survival area rate of veins anastomosed was (98. 6 ± 9. 7) %.

CONCLUSIONSPerforator propeller flaps with anastomosis of superficial veins can improve the flap venous drainage, avoid transient venous venous congestion, so as to increase the flap survival. It is an effective way for improving the vein drainage.

Anastomosis, Surgical ; methods ; Debridement ; Extremities ; blood supply ; Graft Survival ; Humans ; Leg Ulcer ; pathology ; surgery ; Perforator Flap ; transplantation ; Regional Blood Flow ; Tibial Arteries ; Ulnar Artery ; Ultrasonography, Doppler, Color ; Veins ; surgery

OBJECTIVETo investigate the clinical application of flow-through deep inferior epigastric perforator flaps for reconstruction of large defects at the extremities.

METHODSThe deep inferior and superior epigastric arteries were designed as the axial vessel and the arterial supply to the flap was the paraumbilical perforator artery. Free deep inferior epigastric perforator flaps were harvested in flow- through manners to reconstruct associated arterial defect in the wound. The sensation assessment,Enneking score,and questionnaire of the flap aesthetic were all performed during follow-up period.

RESULTSFrom December 2011 to September 2012, 5 patients with large defects at extremities were treated. The deep inferior and superior epigastric arteries were designed as the axial vessel and the arterial supply to the flap was the paraumbilical perforator artery. The wound defects ranged form 11 cm x 5 cm to 30 cm x 11 cm. And the flap size ranged from 13 cm x7 cm to 33 cm x 13 cm. All flaps survived completely. The recipient arteries were all bypassed well documented by color Doppler examinations. All cases had 12-24 months' follow-up period. The flaps had good appearance and high aesthetic satisfactory(100%). 12 months after operations, sensation assessment were all S3+, and the Enneking score ratios were 82%-95% ,with 87.2% in average.

CONCLUSIONSFlow-through deep inferior epigastric perforator flaps are reliable and effective for reconstruction of large defects at the extremities with maintenance of the vascular status of the extremities. The flaps can also be designed in transverse or oblique mode for clinical application.

Aged ; Arteries ; Epigastric Arteries ; Esthetics ; Extremities ; blood supply ; surgery ; Humans ; Leg Injuries ; surgery ; Perforator Flap ; blood supply ; Reconstructive Surgical Procedures

INTRODUCTIONEarly debridement and coverage has long been regarded as the standard of care for open fractures of the lower limb, as infection is a serious complication. However, the best time for wound closure remains controversial. Negative-pressure wound therapy (NPWT) is thought to result in reduced flap infection and failure. To determine the effect of NPWT, we reviewed patients with open fractures of the lower limb and compared the rates of infection and flap failure in two time-based cohorts.

METHODSTwo cohorts of patients (periods 2003-2004 and 2008-2009) with Gustilo type IIIB open tibial fractures were recruited and their outcomes were compared. In the 2003-2004 cohort, wounds were dressed with occlusive dressing. In the 2008-2009 cohort, all patients underwent NPWT. Data was retrospectively analysed with regard to infection, failure, age, type of flap, comorbidities and defect size. The incidences of infection and flap failure were further analysed for any statistical difference between the different treatment protocols.

RESULTSIn the 2003-2004 cohort, 33% of patients developed infection and 11% had flap failure. However, in the 2008-2009 cohort, 10% of patients developed infection and 6% had flap failure. The difference in the incidence of infection was statistically significant between the two cohorts (p = 0.029).

CONCLUSIONPatients in the 2008-2009 cohort had better outcomes, and we are of the opinion that performing NPWT may have contributed to this result.

Adult ; Aged ; Cohort Studies ; Debridement ; methods ; Female ; Follow-Up Studies ; Fracture Fixation, Internal ; adverse effects ; methods ; Fractures, Open ; diagnosis ; surgery ; Graft Rejection ; Humans ; Injury Severity Score ; Leg Injuries ; diagnosis ; surgery ; Male ; Middle Aged ; Negative-Pressure Wound Therapy ; Radiography ; Retrospective Studies ; Surgical Flaps ; blood supply ; Surgical Wound Infection ; diagnosis ; surgery ; Tibial Fractures ; diagnostic imaging ; surgery ; Treatment Outcome ; Wound Healing ; physiology ; Young Adult

Compartment syndrome of the thigh is a rare condition, potentially resulting in devastating functional outcome. Increasing intracompartmental pressure which suppresses microcirculation and capillary perfusion may lead to cellular anoxia and muscle ischemia. The muscle compartments in the thigh have a more compliant fascia and blend anatomically into the open compartments of the pelvis, thus compensating higher volumes than the compartments in the lower leg. We present a previously unreported case in which the limb of a 36-year-old man was run over by a 25-ton truck. He presented with a sensomotor deficit in his left lower leg with full paralysis of the shank muscles and absence of all foot pulses. CT scan showed a huge haematoma in the thigh with active bleeding out of the popliteal artery into the haematoma which has already expanded into the muscle compartments of the lower leg. The limb had a disastrous compartment syndrome of the thigh and lower leg with disruption of the popliteal neurovascular bundle; however, no bones in the limb were fractured. A complete fasciotomy of all the lower limb muscle compartments was immediately performed. The artery was reconstructed with interposition of the smaller saphenous vein, which was already interrupted through the initial trauma.
Accidents, Traffic ; Adult ; Compartment Syndromes ; physiopathology ; Humans ; Leg ; blood supply ; innervation ; Male ; Thigh ; blood supply ; innervation

INTRODUCTIONThe gold standard for evaluation of the lower extremity arterial tree is catheter angiography. Duplex arterial-occlusive imaging or duplex ultrasonography arteriography, a noninvasive technique, is used as the first-line investigation in patients with peripheral vascular disease at our centre. Based on the results of duplex imaging, patients who require angiographic intervention then proceed with simultaneous catheter arteriography and intervention. This study aimed to compare the results of duplex imaging alone as the first-line investigation against the eventual results of catheter angiography, and to assess the impact of the former on patients' clinical outcomes.

METHODSAll cases involving patients who underwent duplex imaging followed by angiographic intervention, from May 2008 to February 2009, were discussed at weekly interdisciplinary meetings. Only patients who underwent lower limb imaging were included in the study. Those who were involved in grafts and stent surveillance studies, as well as those with incomplete duplex images were excluded.

RESULTSDuring the study period, 113 duplex imaging studies of the lower limb followed by percutaneous transluminal angioplasty were performed at our hospital for peripheral vascular disease. The iliac artery was visualised in 40 images, but could not be visualised in 73 images. There was a potential change in management in three cases due to radiological differences between the duplex images and angiography films.

CONCLUSIONIn our series, duplex imaging was found to be accurate enough to guide initial clinical management of patients with peripheral vascular disease. This modality is the preferred first-line investigation for such patients at our centre.

Angiography ; methods ; Angioplasty ; methods ; Arterial Occlusive Diseases ; diagnosis ; diagnostic imaging ; Humans ; Leg ; blood supply ; diagnostic imaging ; Peripheral Vascular Diseases ; diagnosis ; diagnostic imaging ; Predictive Value of Tests ; Reproducibility of Results ; Ultrasonography ; methods ; Ultrasonography, Doppler, Duplex ; methods

OBJECTIVETo evaluate the surgical techniques for acute left deep venous thrombosis (LDVT) secondary to left iliac vein compression syndrome (IVCS).

METHODSThirty-six patients with acute LDVT secondary to IVCS received inferior vena cava filter placement, and in 2 of the cases, stent implantation was canceled for acute episode of obsolete DVT. The remaining 34 patients underwent left femoral venotomy for iliofemoral thrombectomy with Fogarty catheter and distal femoral vein thrombus removal by sequential compression of the legs, followed by implantation of stent-graft (2 cases) or bare-metal stents (32 cases) in the left common iliac veins. With routine anticoagulation and thrombolytic treatments, the patients were regularly examined for postoperative blood flow in the affected limb.

RESULTSIn 2 of the cases undergoing bare-metal stent implantation, the residue thrombi were squeezed into the stent by balloon, which was managed subsequently with local thrombolysis. One patient with bare-metal stent implantation received a secondary stenting for posterior stent displacement. Three patients had self-limited bleeding due to decreased serum FBG. Significant improvements were achieved at 3, 6, 30 and 180 days postoperatively in the circumferences of the affected limb (P<0.05) and in the levels of D-dimer (P=0.011), and FBG level showed no significant variations (F=1.163, P=0.345). The total rate of excellent outcomes was 83.3% (26/34) with a total effective rate of 91.2% (31/34) in these cases.

CONCLUSIONSThrombectomy to revascularize the inflow tract and stent implantation to enlarge stenosed iliac veins are key issues in treatment of acute LDVT secondary to IVCS.

Adult ; Aged ; Angioplasty, Balloon ; Female ; Humans ; Leg ; blood supply ; Male ; May-Thurner Syndrome ; complications ; surgery ; Middle Aged ; Thrombectomy ; methods ; Vascular Patency ; Venous Thrombosis ; etiology ; surgery ; Young Adult

OBJECTIVETo evaluate the therapeutic effect of dominant perforator neurocutaneous flaps for one-staged reconstruction of defects caused by high energy at lower legs, ankles and feet.

METHODSFrom July 2003 to Feb. 2011, 39 cases, with defects caused by high energy at lower legs, ankles and feet, were retrospectively studied. The defects were covered primarily by one or two perforator neurocutaneous flaps (free or pedicled) which were based on a dominant perforator arising from the posterior tibial or peroneal artery (including the lateral supramalleolar perforating artery which is also from the peroneal vessel) respectively through sural, saphenous and superficial peroneal neurocutaneous vascular axis.

RESULTS39 cases with 44 defects were treated by 32 sural neurocutaneous flaps based on the peroneal perforator (5 free and 27 pedicled), 6 saphenous neurocutaneous flaps on the posterior tibial perforator (1 free and 5 pedicled) and 6 superficial peroneal ones on the lateral supramalleolar perforating artery. The largest flap size was 22 cm x 10 cm. All flaps were survived successfully without necrosis. The average in-hospital time was 23 days ( ranged from 12-36 days).

CONCLUSIONSThe three kinds of dominant perforator neurocutaneous flaps have reliable blood supply with a relatively large size. They can be chosen and designed individually for all kinds of defects over the lower leg, ankle and foot. There are many advantages in a primary procedure, such as easier dissection, better vessel status in or around recipient areas, less secondary necrosis and lower risk of chronic infection. Moreover, the reduction of granulation and scar tissues benefit functional rehabilitation.

Adolescent ; Adult ; Ankle Injuries ; surgery ; Child ; Female ; Humans ; Leg Injuries ; surgery ; Male ; Middle Aged ; Perforator Flap ; blood supply ; innervation ; Reconstructive Surgical Procedures ; methods ; Retrospective Studies ; Skin Transplantation ; methods ; Soft Tissue Injuries ; surgery ; Young Adult