The venous circulation

Some aspects of the circulation through the veins remain unexplained. The pressure gradient which ordinarily exists across a large vein, for example, is much greater than that necessary to maintain the same flow through a rigid tube of identical diameter (Brecher, 1956; Starling and Evans, 1962). During inspiration, blood flow through the thoracic portion of the inferior vena cava increases markedly, while that through the distal abdominal portion does not change. Furthermore, an active source of pressure drop in the chest is necessary to maintain venous flow. For the open chest the pressure drop occurs mainly during ventricular contraction, while in the closed chest it is produced chiefly by inspiration. The present study indicates that the high distensibility of the veins accounts in significant degree for the behavior characteristic of the venous circulation.     

The venous circulation

Some aspects of the circulation through the veins remain unexplained. The pressure gradient which ordinarily exists across a large vein, for example, is much greater than that necessary to maintain the same flow through a rigid tube of identical diameter (Brecher, 1956; Starling and Evans, 1962). During inspiration, blood flow through the thoracic portion of the inferior vena cava increases markedly, while that through the distal abdominal portion does not change. Furthermore, an active source of pressure drop in the chest is necessary to maintain venous flow. For the open chest the pressure drop occurs mainly during ventricular contraction, while in the closed chest it is produced chiefly by inspiration. The present study indicates that the high distensibility of the veins accounts in significant degree for the behavior characteristic of the venous circulation.     

Arterial and venous circulation of the leg after intermittent venous occlusion

We study the arterial and venous circulation of the normal leg by strain gauge plethysmography and venous occlusion (thigh tourniquet). We propose the application of a simplified linear physical model of the venous circulation. It helps to analyse the plethysmographic data recorded during and after the congestion. It ignores the arterial inflow and consider the post-occlusive venous volume decay in function of time as being monoexponential. The venous compliance (C) is measured when the volume has reached a steady-state level during the congestion (known pressure). The time-constant (T) characterizes the volume decay in function of time when the occlusion is released. The tourniquet is successively inflated with two levels of pressure (30 and 60 mm Hg) in order to check if the system is actually linear as predicted by the model. The venous outflow is not strictly monoexponential and the model is only suitable to describe the beginning of the curve. The compliance does not behave linearly, the values measured at 30 mm Hg, being higher than at 60 mm Hg ($ 26%). The time-constant T is slightly influenced by the level of pressures. The calculated resistance is therefore lower at low pressure. We also study the arterial inflow before and after the venous congestion (3 min, 60 mm Hg). We observe a post-venous occlusion hyperaemia (mean rest flow: 5.2%/min, mean hyperemic flow: 12.1%/min) followed by a drop of the inflow (mean minimal flow: 3.4%/min). We evaluate the quantitative influence of neglecting the arterial inflow on the computing of the venous properties. The simplification appears acceptable.     

Pulmonary venous occlusive disease

The present study deals with the radiation diagnosis of the rare disease--pulmonary venous occlusive disease. The follow-up covered three cases that ended with death. The clinical picture of the disease did not differ from the manifestations of primary pulmonary hypertension. All the patients underwent chest X-ray study in four standard projections. The morphological verification of its diagnosis was made on the basis of autopsy data. X-rat study promoted identification of such signs as peculiar changes in the lung pattern in form of its looping, reticulation, fine-focality along with reticular changes, the presence of Kerley lines, the diameter of root branches, enlargements of the pulmonary trunk without any symptoms of the enlarged left atrium.     

Peripherally inserted central venous catheters. Low-risk alternatives for ongoing venous access.

We prospectively evaluated the use of peripherally inserted central venous catheters to provide ongoing venous access in general medical and surgical patients in a Department of Veterans Affairs medical center. Between 1985 and 1988 trained nurses successfully inserted 393 catheters in 460 suitable patients (an 85.4% success rate). Correct catheter tip placement in the superior vena cava was documented in 359 of the 393 (91.3%) catheter insertions, but an additional 30 catheters were in a position deemed adequate for the intended use. The mean duration of catheter use was 27.6 +/- 5.2 (1 standard deviation) days (median 20 days, range 1 to 370 days). A total of 65 patients left the hospital with catheters in place, with the mean length of catheter use at home being 36.2 +/- 6.0 days (range 2 to 266). In all, 79% of the catheters were in use until the successful completion of therapy or patient death; catheter-related complications led to premature catheter removal in the remaining 21%. Catheter-related complications included bland phlebitis (8.2%), occlusion (8.2%), local infection (3.6%), bacteremia or fungemia (2.1%), mechanical failure or rupture (2.6%), venous thrombosis (0.7%), and other (3.3%). One patient required vein excision for the management of suppurative phlebitis, but no deaths were attributed to catheter use. This study illustrates the use and safety of peripherally inserted central venous catheters to provide reliable vascular access over prolonged periods in an elderly veteran population. At our facility, percutaneous central venous catheters and surgically implanted (Hickman or Broviac) catheters are now reserved for use in patients in whom peripherally inserted catheters cannot be placed.     

Proteomic analysis of venous thromboembolism

Venous thrombosis has a multicausal basis, and is characterized by a multifaceted combination of inherent phenotypic complexity and genetic predisposition, with acquired and triggering factors further and acutely influencing the likelihood of an individual experiencing a clinically significant thrombotic event. Traditional coagulation tests, especially clot-based assays, are useful for describing major abnormalities in the hemostatic response, but fail in their application to assessing thrombotic risk in the healthy population. Recent evidence also attests that the analysis of a vast array of genes can only explain part of the individual thrombotic risk. Thus, proteomic analysis may hold promise for characterizing or understanding biological pathways and pathophysiological interactions, for improving the diagnosis and identifying novel therapeutic approaches to this prevalent and life-threatening disorder. Herein, we present and discuss available data on proteomic analysis of venous thromboembolism, concluding that further studies supported by high-throughput techniques should be undertaken to elucidate or understand biological pathways and pathophysiological interactions.     

Another method to prevent venous thrombosis in microsurgery: an in situ venous catheter

Free-flap failure is in the order of 4 to 10 percent. Heparin is more effective at preventing venous thrombosis than arterial thrombosis. This study was undertaken to investigate the efficacy of delivering heparin at a high dose locally but low dose systemically (heparin infusion via a catheter placed proximal to the venous anastomosis) to prevent venous thrombosis in microsurgery. A model of venous thrombosis was first established by a venous inversion graft in the rat femoral vein (this was performed in seven animals and resulted in 100 percent thrombosis). Saline and heparin were delivered proximal to the inverted vein graft to assess the effect of each in preventing venous thrombosis. Flow/patency distal to the inverted vein graft was assessed by observation under the microscope, the milk test, and rate of flow (flowmeter). Saline infused via a catheter proximal to the venous inversion graft resulted in 100 percent thrombosis in 10 animals. Heparin (100 U/ml at 2 to 3 ml/hour) infused through a catheter for 2 hours proximal to the anastomosis resulted in flow in all 10 animals during the infusion. Blood was also taken before beginning the procedure (control) and after the heparin infusion distal to the anastomosis (local partial thromboplastin time) as well as in the contralateral femoral vein (systemic). The control for all animals that received heparin was <3 minutes. The systemic partial thromboplastin time after heparin infusion was <3 minutes in seven animals, 3.3 minutes in two animals, and >7 minutes in one animal. The local partial thromboplastin time distal to the inverted vein graft was >10 minutes in nine animals and 3.7 minutes in one animal. The study also had a clinical component, in which a catheter was placed in a vein of the free flap, and heparin was infused over 5 days. This technique has been used in 83 consecutive free flaps. In three recent free flaps performed on the limbs, the local partial thromboplastin time (close to the anastomosis) was raised but the systemic time was normal. This technique offers a method in preventing venous thrombosis in microsurgery. It is simple to implement and is not associated with the systemic complications of heparin.