Hemodynamic assessment of femoropopliteal venous reflux in patients with primary varicose veins

Purpose: The aim of this study was to assess the anatomic distribution and extent of deep venous reflux in patients with primary varicose veins (PVVs) and to investigate its influence on venous hemodynamics.Methods: Femoropopliteal venous reflux was examined using duplex color Doppler ultrasonography in 356 limbs with PVVs in 240 patients. Photoplethysmography (PPG) was performed using above-knee and below-knee tourniquets to determine the contributions of deep and superficial venous insufficiency.Results: Of 356 limbs with PVVs, 61 (17.1%) had femoropopliteal venous reflux, 42 (11.8%) had superficial femoral venous reflux alone, and 57 (16.0%) had popliteal venous reflux alone. Femoropopliteal venous reflux was associated significantly with clinical symptoms and shortened the half venous refilling time measured by PPG, especially in the presence of incompetent perforating veins. These findings were obtained regardless of the presence of long saphenous vein reflux.Conclusions: Femoropopliteal venous reflux associated with PVVs plays an important role in the pathophysiologic mechanism of venous stasis and influences venous hemodynamics in the presence of incompetent perforating veins and short saphenous vein. (J Vasc Surg 1997 26:260-4.)     

内镜下深筋膜下交通支离断术治疗老年下肢慢性静脉性溃疡

目的 :探讨电视内镜下深筋膜下交通支静脉离断术治疗老年下肢慢性静脉性溃疡的可行性。方法 :大隐静脉曲张 6例 (10条肢体 ) ,同时存在浅静脉倒流、交通支静脉功能不全和静脉性溃疡 ,4条肢体深静脉功能不全。手术方法为高位结扎大隐静脉 ,分段抽剥 ,内镜下行深筋膜下交通支离断术 ,1例行股静脉戴戒术。结果 :术后肢体症状和浅静脉曲张消失 ,肢体溃疡或皮炎 3周内愈合。结论 :内镜下深筋膜下交通支结扎术具有微创、有效的特点 ,是治疗下肢静脉功能不全性溃疡的有效方法     

静脉曲张术后深静脉内径及功能变化的研究进展

原发性下肢静脉曲张是由于血液由深静脉向浅静脉反流而引起的.高压反流的血液通过反流点远心端的一支或多支穿静脉回流入深静脉,从而形成了"深静脉-浅静脉-穿静脉-深静脉"之间的无效循环.进入该循环的血液增加了穿静脉及深静脉的血流负荷,导致二者扩张,继而可能出现功能不全,此即为"超载理论".而不同类型的静脉曲张手术,若能有效阻...     

Angioscopy-assisted valvuloplasty for primary deep venous valvular insufficiency

Primary deep venous valvular insufficiency causes reflux syndrome. Angioscopy permits the surgeon not only to ascertain that venous valves have not been destroyed but to perform external valvuloplasty under visual control with the valves under pressure. We have performed angioscopy-assisted venous valvuloplasty in three men (mean age 36 years; range 30 to 38 years) and one woman (age 58 years). All four patients had class 3 disease (SVS/ISCVS classification). Descending phlebograms showed grade 3 reflux in one patient and grade 4 reflux in three patients. In all patients angioscopy-assisted valvuloplasty of the superficial femoral vein was combined with wrapping with a segment of polytetrafluoroethylene prosthesis, stripping of incompetent superficial veins, and subfascial ligation of perforating veins. Mean follow-up was 12 months (range 6 to 17 months). In three patients ulcers healed and did not recur; in the remaining patient nearly complete healing was obtained after skin grafting. In all patients ambulatory venous blood pressure improved significantly and venous filling time returned to normal (> 15 seconds). At duplex ultrasonography and descending phlebography, no residual reflux was demonstrated. At final follow-up, all repaired valves were patent and competent. Our experience demonstrates that angioscopy-assisted venous valvuloplasty combines the accuracy of valvuloplasty by means of phlebotomy and the simplicity of external valvuloplasty and thus is preferred to either of these methods.     

下肢静脉曲张伴溃疡患者的病因分析和疗效观察

目的 探讨下肢静脉曲张伴溃疡(C6级)患者的常见病因和治疗效果,为临床诊治提供参考.方法 收集2020年7月至2021年12月深圳市第二人民医院收治的84例下肢静脉曲张伴溃疡患者的临床资料(共86条患肢),汇总患者的下肢静脉彩色多普勒超声和顺行造影检查数据,观察患肢的髂静脉压迫情况、深静脉瓣膜反流情况和穿通支静脉反流情...     

下肢静脉曲张术后复发的原因分析(附46例报告)

目的分析下肢静脉曲张术后复发的原因。方法总结中山大学附属第二医院2002年6月至2004年8月收治的46例（52条患肢）下肢静脉曲张术后复发病人的临床资料，其中合并下肢静脉性溃疡20例（24条患肢）。所有病人均行深、浅静脉及交通静脉彩色多普勒超声检查和患肢顺行性深静脉造影。结果复发的原因有大隐静脉主干及其部分属支残存（11条患肢），合并交通静脉功能不全（35条患肢），合并深静脉瓣膜功能不全（20条患肢）。出现小隐静脉曲张（10条患肢），深静脉血栓形成后遗症（5条患肢），同时存在3个静脉系统病变（15条患肢）。结论下肢静脉曲张术后复发的原因较为复杂，通常累及3个静脉系统。交通静脉功能不全是导致下肢静脉曲张术后复发的主要原因。术前全面的影像学检查和选择正确的手术方式是避免术后静脉曲张复发的关键。     

Haemodynamic significance of incompetent calf perforating veins

A total of 149 consecutive unselected patients (221 limbs) who presented with signs and symptoms of chronic venous problems (varicose veins with or without ankle oedema, skin changes and leg ulcers) have been studied by clinical examination, ascending deep to superficial venography, Doppler ultrasound and ambulatory venous pressure measurements. Of the limbs, 180 (82 per cent) had varicose veins without obstruction in the deep veins or reflux in the popliteal or femoral veins while 41 (18 per cent) had deep venous disease. Of the 180 limbs with 'primary' varicose veins 110 (60 per cent) did not have incompetent calf perforating veins (group A) while 70 (40 per cent) did (group B). On the basis of the ambulatory venous pressure after calf muscle exercise and the refilling time, the incompetent calf perforating veins of limbs in group B belonged to three subgroups of different haemodynamic significance. In 20 limbs (30 per cent) they were found to be of no haemodynamic significance, in 25 (35 per cent) of moderate haemodynamic significance and in 25 (35 per cent) of major haemodynamic significance. The last were, on clinical examination, indistinguishable from limbs with deep venous disease although they had patent deep veins with competent popliteal valves.     

Improvement in deep vein haemodynamics following surgery for varicose veins.

OBJECTIVE: o analyse the effect of superficial and perforating veins surgery on deep vein incompetence. METHODS: During a six-month period between 2000 and 2001 24 patients (32 limbs) with chronic venous insufficiency (CVI) were treated. They were selected because they had varicose veins and proximal deep vein incompetence with photoplethysmography (PPG) venous refilling time (VRT) <15 s with a below knee tourniquet, and a femoral or popliteal vein reflux time (RT) >1.5 s on duplex ultrasound. The group was divided according to aetiology into 21 legs with primary (Ep) and 11 with secondary CVI (Es). All patients underwent removal of varices with stripping of the saphenous veins, if appropriate. In 21 cases subfascial endoscopic perforating vein surgery (SEPS) was performed to ligate incompetent perforating veins. RESULTS: The average VRT for the entire group increased from 9.8 s before to 15 s after operation (p<0.001, paired t test). In the Ep group the average VRT increased from 11 to 18 s (p<0.001, paired t test), in Es group from 7.5 to 10 s (p>0.001, paired t test). Duplex ultrasonography before surgery showed femoral vein incompetence in 28 and the popliteal incompetence in 26 cases. The average femoral vein RT was 1.9 s before and 1.4 s after surgery (p<0.001, paired t test). The femoral RT in the Ep group decreased from 1.9 to 1.3 s (p<0.001, paired t test) and in the Es group from 1.9 to 1.6 s (N.S.). In the popliteal vein, RT was 1.8 s before, and 1.3 s after surgery (p<0.001, paired t test). The RT in the Ep group shortened from 1.8 to 1.1 s (p<0.001 paired t test) and in the Es group from 1.9 to 1.5 s (N.S.). CONCLUSION: Surgical treatment of varicose veins and of calf perforators results in reduced deep vein reflux. The improvement is most marked in cases of primary venous insufficiency.     

Hemodynamic and clinical improvement after superficial vein ablation in primary combined venous insufficiency with ulceration

Purpose: This study was undertaken to determine the degree of clinical and hemodynamic improvement after surgical ablation of incompetent superficial and perforator veins in limbs with combined deep and superficial venous incompetence manifested by chronic dermal ulceration.Methods: Eleven limbs in 10 patients with class 5 or 6 venous insufficiency (ulceration) were assessed by CEAP (clinical, etiologic, anatomic, pathophysiologic) clinical scores, air plethysmography, color duplex ultrasonography, and phlebography (both ascending and descending). Surgical ablation of superficial and perforating veins was performed, followed by repeat clinical, air plethysmographic, and color duplex ultrasonographic examinations.Results: All 11 limbs had combined deep and superficial vein reflux on the preoperative color duplex ultrasound scan. Clinical symptom scores decreased from 10 to 1.4 after operation. Postoperative air plethysmography demonstrated significant reduction in reflux as measured by the mean venous filling index, which decreased from 12 ± 5 ml/sec to 2.7 ± 1 ml/sec after surgery. Calf pump function was also significantly improved, with a mean ejection fraction that increased from 43% ± 11 to 59% ± 13 and mean residual volume fraction that decreased from 56% ± 15 to 33% ± 16. Each of these measures was significantly different from the preoperative value (p < 0.05). Similar improvement characterized subgroups of limbs with three or more incompetent deep segments (n = 6) or popliteal segment incompetence (n = 6).Conclusions: Superficial and perforating vein incompetence accounts for a substantial and correctable component of venous insufficiency in limbs with combined deep and superficial vein reflux and venous ulceration. These data indicate that surgical correction of this component significantly improves clinical symptoms and venous hemodynamics. Superficial and perforator ablation is an appropriate initial step in the management of combined deep and superficial venous incompetence. (J Vasc Surg 1996;24:711-8.)     

内镜筋膜下交通静脉结扎治疗慢性下肢静脉性溃疡的临床体会

目的:探讨内镜筋膜下交通静脉结扎术(subfascial endoscopic perforator surgery,SEPS)治疗慢性下肢静脉性溃疡的临床效果。方法:回顾分析78例,86条下肢慢性静脉性溃疡患者行内镜深筋膜下交通静脉离断+大隐静脉高位结扎并抽剥术的临床资料。结果:患者术后均恢复良好,浅静脉曲张消失,溃疡愈合,未发生明显并发症,随访1~3年,无皮肤溃疡及浅静脉曲张复发。结论:大隐静脉高位结扎剥脱术+SEPS治疗下肢静脉性溃疡有效,患者创伤小、康复快,效果好。     

Assessment of venous muscle pump function by ambulatory calf volume strain gauge plethysmography after surgical treatment of varicose veins: a prospective study of 21 patients

A prospective study of the improvement in leg muscle pump function after radical surgery was performed for treatment of varicose veins. Venous muscle pump function was assessed in 21 patients with primary varicose veins by means of ambulatory strain gauge plethysmography immediately before surgery and 3 months and 60 months after surgical treatment of varicose veins. The physiologic documentation of the operative efficacy was provided by the mean venous reflux, which was reduced by 54% (p less than 0.001), and the mean expelled volume, which was increased by 58% (p less than 0.001). Initially, all patients had improved venous muscle pump function. This improvement was still present 60 months after surgery. At clinical assessment 3 months after surgery, it was noted that 90% of the patients were without residual varicose veins (p less than 0.01). Sixty months after surgery, 71% of the patients were without apparent varicose veins (p less than 0.05). Subjective symptoms had virtually disappeared 3 months after surgery (p less than 0.001) but were found to a variable extent in 80% of the patients at the 60-month control follow-up. It is concluded that ambulatory strain gauge plethysmography may quantitate the effect of surgery in patients with venous valvular incompetence; in addition to measurements of refilling time, it is able to measure the muscle-pump-generated expelled volume because of in-place electrical calibration.     

Relationship of venous reflux to the site of venous valvular incompetence: implications for venous reconstructive surgery

To evaluate the relationship of the site of venous valvular incompetence to the severity of venous reflux, legs of 71 patients with suspected chronic venous insufficiency were evaluated with Doppler ultrasonography and photoplethysmography. A venous recovery time (VRT) of less than 20 seconds after calf muscle exercise was considered indicative of significant reflux. Average VRTs were brief in 15 legs with stasis changes (10 +/- 7 seconds), longer in 42 legs with edema (26 +/- 23 seconds), and normal in 64 asymptomatic legs (37 +/- 24 seconds) and 16 legs with pain (53 +/- 19 seconds). Average VRTs in limbs with incompetent saphenous veins were abnormal. In limbs with competent superficial veins, only those with incompetent distal deep veins (popliteal and posterior tibial) had abnormal VRTs (14 +/- 10 seconds). VRTs in limbs with no detectable valvular incompetence and in those with incompetence limited to the proximal deep veins (common and superficial femoral) were normal (47 +/- 23 and 42 +/- 27 seconds, respectively). When superficial veins were incompetent, an ankle tourniquet normalized VRTs in 63% of legs with proximal deep venous incompetence and in only 33% of legs with distal deep venous incompetence. It is concluded that venous reflux is largely determined by saphenous and distal deep valvular function and that competence of the proximal valves has little effect. Decreased venous reflux would not be expected after proximal valvular reconstruction.     

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目的：探讨下肢原发性静脉返流性疾病的综合外科治疗效果,方法：从1996年2月至2000年9月,对患者肢原发性静脉返流性疾病的108例126条肢体进行了综合性外科手术治疗,所有肢体均行浅静脉手术,83例97条肢体在浅静脉手术同时行股静脉瓣外修复成形成,22例26条同时行股静脉瓣膜外修成形术＋腔镜筋膜下交通静脉结扎术（SEPS）,3例3条同时行SEPS。结果：80．2％（１０１／１２６）的患肢静脉性跛行,酸胀,疼痛等症状消失,１９．８％（２５／１２６）的患肢状明显改善,所有肢体静脉曲线消失,行浅和深静脉系统手术的肢体中有１０条合并溃疡,术后３－６个月,有８条溃疡愈合,２条明显缩小,在浅或（和）深静脉手术基础上加作ＳＥＰＳ的２３例２６条肢体的静脉性溃疡,有２４条术后１４－３2d愈合,２条也明显缩小,全组经彩超复查８９．７％的肢体深静脉瓣膜功能恢复正常,结论：对重度下肢原发性静脉返流性疾病人的浅静脉,深静脉和交通静脉三个系统的疾病变同时综合性的给予外科治疗,可大大提高临床疗效。     

Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: long-term follow-up

PURPOSE: Subfascial division of incompetent perforating veins seems to be a successful treatment for patients with venous leg ulceration (CEAP 6). For postoperative wound complications, endoscopic techniques are more common than open subfascial division of incompetent perforating veins (Linton procedure). We investigated the long-term results of ulcer healing and recurrence rates and compared them with preoperative and postoperative duplex findings. METHODS: Patients with venous ulceration on the medial side of the lower leg were randomly allocated to endoscopic exploration or open exploration by means of the modified Linton approach. Ulcer healing and recurrence rates were documented. RESULTS: Thirty-nine patients were randomly allocated to exploration, 19 patients to open subfascial division of incompetent perforating veins (Linton group), and 20 patients to subfascial endoscopic division of incompetent perforating veins (SEPS group). During the follow-up period, four patients in the SEPS group died, all of causes other than the venous leg ulcer. Because of a squamous cell carcinoma that had developed in the venous ulcer, one patient in the SEPS group underwent a below-knee amputation. In a mean follow-up period of 50.6 months, the venous ulceration of all 18 patients in the Linton group who were available for follow-up initially healed. The recurrence rate in this group was 22% (4 patients). In the SEPS group, the mean follow-up period for 19 patients was 46.1 months, with the ulceration healing in 17 patients and a recurrence rate of 12% (2 patients). The presence of deep venous incompetence (DVI) did not influence the recurrence rates (P =.044, Fisher exact test), but it significantly influenced the development of new incompetent perforating veins (3 of 10 without DVI; 7 of 10 with DVI; P =.011, binomial test). CONCLUSION: The long-term follow-up results of the endoscopic division of perforating veins are comparable with those of the open division of perforating veins (modified Linton procedure).     

Surgical treatment for advanced chronic venous insufficiency in Hong Kong

Advanced chronic venous insufficiency (CVI) is an important health problem. In Hong Kong, with its predominantly Chinese population, most patients have primary CVI because deep vein thrombosis is less common. Nevertheless, 80% of the limbs with advanced CVI had reflux in both the superficial and deep vein systems. This showed that advanced CVI in this population is a multisystem pathological condition affecting both the superficial and deep vein systems. In the present study, it was hypothesized that the abnormal hydrostatic forces in the superficial and perforating vein systems are the significant pathologic forces leading to advanced CVI, although deep vein incompetence is common. This deep vein incompetence can be contributed to significantly by venous overload as a result of superficial reflux (reflux circuit of venous overload). This is well supported by the abolition of deep venous reflux as well as significant haemodynamic improvement as measured by air plethysmography after superficial vein surgery in limbs with mixed superficial and deep venous incompetence. Recently, subfascial endoscopic perforating vein surgery (SEPS) was introduced as a minimally invasive technique to interrupt incompetent calf perforators. Preliminary local experience showed that SEPS with concomitant superficial vein surgery was associated with a 97% ulcer healing at a mean follow up of 15 months. Significant haemodynamic improvement was also shown by air plethysmography. However, recurrent ulcers were noted in 15% of the limbs. Thus, SEPS with superficial vein surgery where appropriate can be the optimal operative treatment strategy for advanced CVI in the local population, although ulcer recurrence remains a concern.      

Randomized clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping

BACKGROUND: This randomized trial was undertaken to investigate the fate of incompetent perforating veins (IPVs) following saphenofemoral ligation and stripping of the great saphenous vein (GSV), with or without subfascial endoscopic perforator surgery (SEPS). METHODS: Patients with venous reflux (greater than 0.5 s) of the GSV and additional IPVs were allocated randomly to standard surgery (saphenofemoral ligation, stripping and phlebectomies alone) or with the addition of SEPS. Patients with ulceration, recurrent veins, deep venous reflux/thrombosis or saphenopopliteal reflux were excluded. Duplex ultrasonography was carried out before operation, and at 1 week, 6 weeks, 6 months and 1 year after surgery. Quality of life questionnaires were completed and visual analogue scale scores collected at the same time points. RESULTS: Thirty-eight patients were allocated to SEPS and 34 to the no SEPS group. Two patients in the no SEPS group were excluded (one withdrew and the other had the wrong treatment). There were no differences between the two groups with respect to pain, mobility or quality of life scores during follow-up. A significantly higher proportion of patients in the no SEPS group had IPVs on duplex imaging at 1 year (25 of 32 versus 12 of 38; P < 0.001). CONCLUSION: IPVs do not remain closed following standard varicose vein surgery. The addition of SEPS was not associated with significant morbidity but did reduce the number of IPVs. Up to 1 year this had no effect on recurrence rates or quality of life, but late results remain to be seen. Registration number: ISRCTN18288048 (http://www.controlled-trials.com).     

An evaluation of Doppler ultrasound and photoplethysmography in the investigation of venous insufficiency.

Non-invasive methods of venous assessment have been developed to improve diagnostic accuracy in the assessment of venous insufficiency. Of these, continuous wave Doppler (CWD) ultrasound and photoplethysmography are the cheapest and most simple to perform. In this study duplex scanning was used to test the accuracy of these two methods. One hundred and thirty-six patients attending the venous outpatient clinic at Middlesex Hospital, London were examined by all three techniques and a diagnosis was reached using each technique. The technicians performing the examinations were unaware of the diagnoses reached by the other methods. Continuous wave Doppler ultrasound was found to be most accurate in the diagnosis of long saphenous incompetence (sensitivity 73%, specificity 85%). Due to the variability of venous anatomy at the popliteal fossa and the 'blindness' of the technique, it was inaccurate in the diagnosis of short saphenous incompetence (sensitivity 33%) and deep vein reflux (sensitivity 48%). Photoplethysmography was found to be most accurate in the diagnosis of deep vein reflux (sensitivity 79%, specificity 70%) but was inaccurate in identification of the site of superficial vein reflux. Inaccuracies may be attributed to the presence of incompetent perforating veins and variation in arterial inflow.     

Surgical treatment of chronic venous insufficiency

Results of surgical treatment of 700 patients with chronic venous insufficiency of the lower extremities are presented. Subfascial endoscopic ligature of perforating veins and catheteric truncal sclerotherapy of v. saphena magna was applied by the authors side by side with traditional operations--venectomy and ligature of perforating veins. In the patients, treated using miniinvasive methods, the lowest frequency of purulent postoperative complications, the veins varicosis and the trophic ulcers recurrence was registered. Good immediate and late follow-up results achieved are due to meticulous selection of patients depending on the venous insufficiency stage and the deep venous system passability. It is necessary to proceed with further investigation of possibilities of the perforating veins endoscopic subfascial ligature and of catheteric truncal sclerotherapy performance in other stages of the disease.     

AN EVALUATION OF DOPPLER ULTRASOUND AND PHOTOPLETHYSMOGRAPHY IN THE INVESTIGATION OF VENOUS INSUFFICIENCY

Non-invasive methods of venous assessment have been developed to improve diagnostic accuracy in the assessment of venous insufficiency. Of these, continuous wave Doppler (CWD) ultrasound and photoplethysmography are the cheapest and most simple to perform. In this study duplex scanning was used to test the accuracy of these two methods. One hundred and thirty-six patients attending the venous outpatient clinic at Middlesex Hospital, London were examined by all three techniques and a diagnosis was reached using each technique. The technicians performing the examinations were unaware of the diagnoses reached by the other methods. Continuous wave Doppler ultrasound was found to be most accurate in the diagnosis of long saphenous incompetence (sensitivity 73%, specificity 85%). Due to the variability of venous anatomy at the popliteal fossa and the ‘blindness’ of the technique, it was inaccurate in the diagnosis of short saphenous incompetence (sensitivity 33%) and deep vein reflux (sensitivity 48%). Photoplethysmography was found to be most accurate in the diagnosis of deep vein reflux (sensitivity 79%, specificity 70%) but was inaccurate in identification of the site of superficial vein reflux. Inaccuracies may be attributed to the presence of incompetent perforating veins and variation in arterial inflow.     

Perforating veins and venous insufficiency]

As communicating link between the deep and the superficial venous system the perforating veins are of special importance. With the introduction of the subfascial videoendoscopic dissection of the perforating veins the interest in anatomic and topographic aspects of the surgical treatment of insufficient perforators has increased. Different pathophysiological conditions can cause insufficient perforating veins. We can distinguish between a primary form and a secondary form caused by an advanced varicosis of the main superficial veins. A third entity consists in an insufficiency created by a postthrombotic alterations of the deep venous system. Primary insufficient perforators should be treated surgically. In the case of a secondary insufficiency the indication is dependent on the extent of the pathological findings. If there is an obstruction of the deep venous system which causes the insufficiency of a perforator the vein should not be divided. The videoendoscopic subfascial dissection of the insufficient perforating veins has several advantages compared with direct percutaneous exposure. The technique is easy to learn, however it requires profound knowledge about the compartmental spaces and the topographic anatomy of the perforating veins in the lower leg.