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Biomedical subjects

R L Kistner

Publications and source records attributed to R L Kistner.

At least 37 records · Page 2Linked to original sources
PubMed1995

Deep venous valve reconstruction.

The place of deep venous valve reconstruction in the surgical management of the patient with chronic venous insufficiency has become clearer with collected experience over the past 25 years. The reasons to perform surgery in chronic venous disease and the specific rationale for deep venous repair are contrasted with the management of the same patient by medical means. A new classification of chronic venous disease has been developed and provides the basis for a more objective understanding of specific entities in the entire field of chronic venous symptoms. The requirements for diagnosis before reconstructive surgery are stringent and a diagnostic algorithm is discussed in the selection of candidates for deep venous reconstruction. The multiple surgical techniques for deep venous reconstruction include internal intravenous direct valve repair and extravenous tightening of the vein wall around the valve cusp. The results of valve repair for primary valve incompetence are discussed in terms of long-term clinical results, long-term imaging results and long-term physiologic results as reflected by venous pressure examinations. It is becoming increasingly clear with the passage of time and the sharpening of our diagnostic skills that reflux is the dominant cause of chronic venous insufficiency. The ability of surgical procedures to decrease reflux in a diseased extremity can be used to restore patients to their normal way of life free of pain, swelling and ulceration and, in the ideal case, free of the need for elastic support.

Chronic Disease↗
PubMed1995

1994 update on phlebography and varicography.

BACKGROUND: Appropriate management of venous disease requires definitive diagnosis. The place of phlebography and varicography in acute and chronic venous disease is to complement other less invasive and less expensive tests of venous function. OBJECTIVE: This paper will address the present indications for phlebography and present the techniques of ascending and descending phlebography and of varicography practiced in our environment. METHODS: The technique of each type of phlebography are outlined. These include ascending phlebography at the foot, popliteal and femoral levels, varicography, and descending phlebography. Complications are discussed briefly. RESULTS: The advantages and complications of each method are discussed with the description of the procedures. CONCLUSION: The most frequent uses of phlebography in acute venous thrombosis are to define deep vein thrombosis isolated to the calf or to the iliac veins, or to clarify findings from duplex scan examinations. In chronic venous disease, phlebography is used to clarify problem cases of superficial venous disease and to study patients with advanced deep vein disease who are potential candidates for deep vein reconstruction.

Acute Disease↗
PubMed1994

Long-term results of venous valve reconstruction: a four- to twenty-one-year follow-up.

PURPOSE: The purpose of this study is to describe the very long-term clinical, hemodynamic, and imaging results of venous valve reconstruction for reflux disease in patients with chronic venous insufficiency. METHODS: There were 51 extremities (48 patients) with follow-up of 4 to 21 years with a mean of 10.6 years. Clinical severity was graded as asymptomatic (class 0), mildly symptomatic (class 1), moderately symptomatic but without ulceration (class 2), or severely symptomatic with or without ulceration (class 3). Preoperative and postoperative evaluation consisted of history and physical examination, ascending venography (preoperative only), ambulatory venous pressures or photoplethysmography, and descending venography or duplex scanning. RESULTS: Before surgery, 49 (96%) of 51 limbs demonstrated severe, class 3 disease, and two limbs were classified as class 2 disease. After venous valve reconstruction by either direct femoral vein valve repair, transposition, or transplantation, long-term clinical success of achieving a class 0 or 1 result (by life-table analysis) was 60% at 10 years. Thirty-three percent demonstrated a class 0 result in which the limbs were free from symptoms and had no need for long-term elastic support. After 6 years clinical results were stable and did not deteriorate. Incompetent perforators were identified in 31 cases and were treated selectively. Three disease patterns of chronic venous insufficiency were identified: primary valve insufficiency 43%, postthrombotic syndrome 31%, and a group consisting of both primary valve insufficiency of the superficial femoral vein and postthrombotic syndrome of the calf veins (primary valve insufficiency-postthrombotic syndrome) 26%. Ten-year cumulative clinical success was clearly superior in limbs with primary valve insufficiency corrected by valve repair (73%) as opposed to those with postthrombotic syndrome treated by either valve transposition or transplantation (43%) (p = 0.029). Clinical outcome correlated strongly with postoperative imaging results, and durability of valve repair was confirmed by demonstrating competence up to 16 years after the operation. Significant improvement in ambulatory venous pressure (mean percentage of pressure fall and refill time) was found in limbs with class 0 or 1 outcome; however, values did not reach "normal" levels in all cases. Recurrent ulcerations after the operation were attributed to failed reconstructions (10), incompetent profunda femoris veins (three), incompetent perforators (three), and concomitant lymphedema (one). CONCLUSIONS: This report highlights a difference found in very long-term prognosis of surgical treatment of primary valve insufficiency as opposed to postthrombotic syndrome. Long-term elimination of symptoms of chronic venous insufficiency is achieved by valve repair for primary valve insufficiency beyond 10 years, whereas late results of treatment of postthrombotic syndrome in this study was accompanied by high recurrence rates and warrants further investigation.

Axillary Vein↗
PubMed1994

Prospective study of duplex scanning for venous reflux: comparison of Valsalva and pneumatic cuff techniques in the reverse Trendelenburg and standing positions.

PURPOSE: To achieve uniform testing of venous reflux between institutions, comparable methods of testing by duplex scanning are desired. This study directly examines differences of testing by two techniques, Valsalva and rapid cuff deflation, performed in two positions: 15-degree reverse Trendelenburg (RT-15) and standing. METHODS: Duplex examination of 22 extremities in 19 patients with moderate to severe, class 2 and 3 chronic venous insufficiency symptoms were compared with duplex scanning of 21 limbs in 11 normal, healthy volunteers. Duration of retrograde flow and peak velocity were measured in 247 venous segments. All extremities were studied in four ways: RT-15 Valsalva, standing Valsalva, RT-15 cuff, and standing cuff. Reflux was defined as duration of retrograde flow or reflux time greater than 0.5 seconds. Six venous segments were examined: common femoral, superficial femoral, deep femoral, and greater saphenous in the upper thigh, popliteal, and posterior tibial (at the ankle). RESULTS: The results of testing the Valsalva technique and the cuff in both the RT-15 and standing non-weight bearing positions indicate that the Valsalva method is best performed in the RT-15 position as opposed to standing, whereas the cuff technique is more effective in the standing position. In symptomatic limbs, the RT-15 Valsalva method showed similar proportion of reflux in the upper thigh when compared with the standing cuff method: common femoral (90% vs 67%), superficial femoral (81% vs 71%), greater saphenous (88% vs 59%), and deep femoral veins (30% vs 15%). In the popliteal vein the standing cuff test showed similar proportion of reflux (77%) as compared with the RT-15 Valsalva test (68%); however, a case-by-case analysis identified a large amount of variability between techniques, and inconsistencies could not be used to identify one technique as better than the other. Examination of the posterior tibial veins by all methods produced inconsistencies and a low yield of reflux in symptomatic limbs. In the common femoral vein, RT-15 Valsalva testing produced reflux times of up to 1.5 seconds in normal limbs, and represented "physiologic reflux." There was no recognizable effect of iliac vein valves on testing distal venous segments by Valsalva maneuver. CONCLUSIONS: Reflux in the upper thigh veins--common femoral, superficial femoral, deep femoral, and greater saphenous-is similarly demonstrated in both normal and symptomatic states by cuff deflation and RT-15 Valsalva techniques. In the popliteal vein, discrepancies between these two techniques are identified in patients with chronic venous insufficiency, and tibial vein reflux is not well demonstrated by either technique. Further investigation is needed to determine ideal techniques for identifying popliteal and tibial vein reflux.

Adult↗
PubMed1993

Complete abdominal exploration is unnecessary during the treatment of cholelithiasis.

The development of laparoscopic and non-operative methods for the management of cholelithiasis has been based on the premise that abdominal exploration during cholecystectomy is unnecessary. In the current study, 305 patients undergoing complete abdominal exploration during routine cholecystectomy were evaluated to assess the incidence and significance of intraabdominal pathology found at the time of exploration. While 41 patients (13.4%) were found to have additional diagnosis at the time of exploration, the majority of these were either minor in nature or would easily have been recognized utilizing laparoscopic techniques. Only one patient would have had significant intraabdominal pathology missed by laparoscopic techniques. It can be concluded that abdominal exploration at the time of treatment of cholelithiasis is unnecessary and that laparoscopic cholecystectomy will not compromise patient care in this regard.

Cholecystectomy, Laparoscopic↗
PubMed1992

Prospective comparison of duplex scanning and descending venography in the assessment of venous insufficiency.

A prospective study comparing duplex scanning and descending venography was applied to 143 venous segments in 25 extremities with moderate to severe manifestations of chronic venous insufficiency (class 2 or 3). Duplex scanning was performed with the patient in the 15 degree reverse Trendelenburg position, and descending venography with the patient in the 60 degrees semi-erect position; the Valsalva maneuver was used to elicit reflux in both tests. The duplex parameter of reflux duration greater than 0.5 second correlated with venographic reflux in 94 of 105 segments (sensitivity of 90%). Conversely, reflux time less than or equal to 0.5 second correlated with venographic competence in 32 of 38 segments (specificity of 84%). A total of 17 discrepancies were identified among the 143 total segments studied, for an accuracy of 88%. The largest proportion of discrepancies was identified in the group with venographic competence and reflux duration greater than 0.5 second and less than or equal to 2.0 seconds; this was designated a gray zone. Mean peak velocities were significantly higher in the reflux group when compared with the competence group in the profunda femoris vein (p = 0.047), greater saphenous vein (p less than 0.001), popliteal vein (p less than 0.001), and tibial vein (p = 0.005). We conclude that venographic reflux correlates best with duplex scan findings of reflux duration greater than 0.5 second. Duration of reflux greater than 0.5 second and less than or equal to 2.0 seconds, however, represents a gray zone and should be interpreted with caution since this could lead to over-reading of reflux disease, in which case verification of incompetence by descending venography may be indicated.

Adult↗
PubMed1992

Long-term effects of superficial femoral vein ligation: thirteen-year follow-up.

This study examines the late clinical, hemodynamic, and anatomic results of superficial femoral vein ligation performed in 35 extremities that were followed an average of 13 1/2 years (range, 5 to 22 years). Indications for interruption were to prevent recurrent embolization from distal deep venous thrombosis (14 cases), to prevent emboli in patients with contraindication to anticoagulants (eight cases), to prevent distal reflux in selected patients undergoing iliofemoral thrombectomy (11 cases), and to control reflux in failed venous reconstruction (two cases). Ligation was effective in the prevention of pulmonary emboli as indicated by no significant clinical events and 15 negative postligation ventilation-perfusion scans. Long-term clinical follow-up showed normal (class 0) or near-normal (class 1) extremities in 83%. Fourteen percent developed mild to moderate symptoms of pain or swelling but without ulceration (class 2), and only one case (3%) had ulcerative sequelae (class 3). The only two findings that correlated with worse clinical outcome were the presence of an incompetent profunda femoris or an obstructed greater saphenous vein. Profunda femoris reflux was found in 60% (3/5) of patients with class 2 or 3 sequelae, which was significantly higher than the 14% (3/22) found in those patients with class 0 or 1 results (p < 0.05). Obstruction of the greater saphenous vein was found in 50% of those patients with class 2 or 3 results as opposed to 9% with class 0 or 1 results (p = 0.05). A large collateral vessel between the profunda femoris and the distal superficial femoral or popliteal vein was associated with poor long-term results.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1986

Thromboembolism after hip surgery. Comparison of screening methods.

Venous thromboembolism is a serious and, often, asymptomatic complication of hip surgery. A reliable screening test is needed to detect thrombi early to prevent death from pulmonary emboli. Noninvasive screening tests were ineffective in our study of 453 patients. We recommend early use of ventilation/perfusion lung scanning in all patients after hip surgery. In those who have positive results, ascending venography can be used to localize the thrombus and anticoagulation therapy can be started early.

Female↗
PubMed1986

Carotid endarterectomy. Controversies and recommendations.

Carotid endarterectomy is a comparatively safe procedure for prevention of stroke in carefully selected patients with carotid stenosis. Generally, it is indicated in patients with hemispheric symptoms of transient ischemic attacks (TIAs), but it is more controversial in patients with non-hemispheric TIA symptoms or no symptoms. Emergency endarterectomy in patients with acute TIA symptoms is considered dangerous. Results of a series of 120 endarterectomies performed at Straub Clinic, Honolulu, confirm the benefits of elective endarterectomy when a meticulous operative technique is followed and intraoperative angiography and repair of defects are done. Prophylactic endarterectomy should not be performed unless a very low incidence (less than or equal to 3%) of combined major morbidity and mortality can be achieved.

Carotid Arteries↗
PubMed1986

A method of performing descending venography.

With the recent development of successful methods to correct valve incompetence in the lower extremity, there is a need for a standardized approach to descending venography. This is the single test that accurately defines the site of the venous valve and demonstrates its competence or degree of incompetence. This report describes a technique of descending venography, including the details of catheter placement, injection procedure, and monitoring techniques. Interpretation of the study requires a method that analyzes both the individual valve function and the overall valvular competence of the entire extremity. Descending venography can separate patients with primary valve incompetence from those with postthrombotic valve destruction, as well as the occasional case of valve aplasia. Points on interpretation of valve function and the use of the Valsalva maneuver for "stressing" the valve are discussed. The descending venographic results are compared with the clinical state and with venous pressure findings in 78 extremities.

Arm↗
PubMed1986

Diagnosis of chronic venous insufficiency.

An orderly diagnostic approach is needed to establish specific anatomic and etiologic diagnoses in patients with chronic venous insufficiency. It begins with the history and physical examination, including Doppler examination of the veins, in the office. When the severity of the problem warrants further investigation, the vascular laboratory can be used to assess the degree of physiologic change via pressure, volume, and flow studies. Diagnosis of obstructive and incompetent states can be established, and the one distinguished from the other. Ascending phlebography is used to demonstrate the anatomy of the veins, competence of the perforators, and the presence of postthrombotic deep vein changes. Descending phlebography is used in selected cases to diagnose specific incompetence of the valves in the superficial femoral, deep femoral, and greater saphenous veins. A complete venous evaluation defines which veins are patent, where the valves are located and if they are competent, and provides physiologic pressure and volume studies to correlate with the clinical state. Problems caused by primary valve incompetence are separated from those caused by postthrombotic recanalization or occlusion. On the basis of these findings, specific therapy can be tailored to the problem at hand.

Humans↗
PubMed1985

Thromboembolism following hip fracture.

Two hundred forty-eight patients following hip fracture were studied for deep venous thrombosis and pulmonary embolus. Ventilation-perfusion lung scans and contrast ascending venography were performed on the sixth to eighth postoperative days. Low-dose intravenous heparin (3,000-5,000 units every 6 hours) was followed by a decreased incidence of pulmonary embolism more than twofold. Although heparin administration was not associated with a significantly decreased incidence of deep venous thrombosis as assessed by venographic studies, thrombi in the nonheparin-treated patients were more likely to occur above the knee and were at higher risk for pulmonary embolus. Pneumatic and mechanical compression devices alone did not protect patients from deep venous thrombosis above the knee, but were associated with a decreased incidence of pulmonary embolus compared to control.

Aged↗
PubMed1984

Assessment of chronic venous insufficiency using dynamic venous pressure studies.

In this study, 207 consecutive limbs with chronic venous insufficiency were evaluated with dynamic venous pressure studies and they were correlated with the clinical presentation and results of definitive radiologic studies with ascending and descending venography. Multiple methods of performing the pressure studies, by active exercise, passive manual compression, and tourniquet application at the calf and ankle, proved useful in distinguishing the severity and location of venous disease. The limits of confidence that can be ascribed to the dynamic venous pressure studies were also determined.

Adolescent↗
PubMed1982

Femoral vein reconstruction in the management of chronic venous insufficiency. A 14-year experience.

Clinical, hemodynamic, and venographic studies were performed on 46 patients undergoing reconstruction of the incompetent femoral vein and followed up for 13 years. Operations included 32 valve repairs and 14 vein segment transpositions. Twenty-four patients had perforator vein interruption in addition to valve surgery; 16 had only valve procedures; and six had had previous perforator surgery. The results indicate that ambulatory venous pressure is the most reliable hemodynamic test; it is sensitive but not specific. Descending venography proved the durability of valve repair up to 12 years. Perforator interruption improved the clinical and the hemodynamic outcomes. Good to excellent long-term results were found in 83% of the patients operated on for ulceration and, of those with recurrence, all were seen within the first four postoperative years. Restoration of competence in the femoropopliteal segment produces a long-term favorable effect. Optimal clinical, venographic, and hemodynamic results occur when all abnormal venous divisions (saphenous, perforating, and deep) are corrected.

Adult↗