Patterns of venous reflux in limbs with venous ulcers. Implications for treatment.

AIM: To investigate the anatomic distribution of vein reflux in limbs with healed or active ulcers (CEAP V and VI). METHODS: Sixty limbs (58 patients) belonging to CEAP classes V and VI were identified from 798 limbs (519 patients) with ultrasonically proven chronic venous insufficiency (CVI). Age, gender, duration of the venous ulcer, and history of deep venous thrombosis were correlated to the anatomic distribution of the venous reflux. RESULTS: The prevalence of active or healed ulcers in limbs with CVI was 7.5%. Among 60 limbs with ulcers, primary CVI was present in 34 (56.7%) and post-thrombotic CVI in 26 limbs (43.3%). No difference in age and gender was found between the 2 groups (p=0.2 and p=0.8, respectively). However, the duration of the ulcer was longer in limbs with post-thrombotic CVI (p<0.05). The prevalence of perforator reflux was 41.2% (14/34) in limbs with primary CVI and 38.5% (10/26) in limbs with post-thrombotic CVI (p=0.8). Superficial venous insufficiency, with or without perforating vein reflux, was the commonest pattern in limbs with primary CVI; it was rare in limbs with post-thrombotic CVI (22/34 or 64.7% vs 2/26 or 7.7%, p<0.01). Deep vein insufficiency was present in 35.3% (12/34) of the limbs with primary CVI and in 92.3% (24/26) of the limbs with post-thrombotic CVI (p<0.01). CONCLUSION: Superficial venous insufficiency, with or without perforating vein reflux, was the commonest pattern in limbs with primary CVI, whereas, deep venous insufficiency was present in most of the limbs with post-thrombotic CVI. The prevalence of perforating vein reflux was comparable in both settings. Thus, elimination of superficial reflux is expected to result in ulcer healing of most limbs with primary CVI, whereas, the value of such treatment in post-thrombotic limbs is not clear.     

A new autologous venous valve by intimal flap. One case report

Various surgical techniques have been proposed for the treatment of chronic venous insufficiency of post-thrombotic recanalized deep veins of the lower limbs. The preferable method seems to be represented by intravenous valvuloplasty except for the cases affected by extensive valvular damage. For this reason some experimental autologous, heterologous and prosthetic venous valves have been proposed. Such a problem emerged for 1 patient (male, aged 78 years, right limb, leg dystrophy, multiple ulcerations at the ankle) which was selected by duplex, Doppler venous pressure index, photoplethysmography and ascending phlebography. An iliac-femoral and popliteal post-thrombotic, recanalized, decompensated venous insufficiency and one Cockett's perforator incompetence were diagnosed (CEAP classification: C6s Es As2d14 Pr). A bicuspid apparently repairable popliteal valve was detected by phlebography. A traditional intravenous valvuloplasty was planned but the valve was not found at surgical exploration. A monocuspid valve reconstruction by intimal flap vein was performed. The following results were obtained and controlled after one year: stable ulceration healing, dystrophy reduction, improvement in the quality of life, normalization of the hemodynamic parameters and of the radiological morphology of the new valve. It can be concluded that monocuspid valvular repair by intimal flap can be successfully performed in cases affected by secondary valveless deep venous insufficiency of the lower limbs.     

Clinical presentation and anatomic distribution of chronic venous insufficiency of the lower limb in a typical Mediterranean population.

BACKGROUND: The aim of this study was to demonstrate the characteristics of lower limb chronic venous insufficiency (CVI) in a homogeneous Mediterranean population. METHODS: Investigation of 694 patients with uni- or bilateral symptoms and signs of lower limb CVI using colour duplex scanning. Limbs with previous venous surgery were excluded. The limbs were classified according to history and ultrasonic findings into those with post-thrombotic and those with primary CVI. The clinical presentation according to the CEAP classification was correlated to the anatomic distribution of venous reflux. RESULTS: Most of the symptomatic limbs (537/656, 81.5%) with primary CVI belonged to classes 1 to 3. In these limbs reflux confined to superficial veins was very common (64.5%, 424/656) whereas the prevalence of deep and perforator vein reflux was 18.5 and 25.5%, respectively. In contrast most of the limbs (69.5%) with post-thrombotic CVI belonged to classes 4 to 6, had a complex pattern of reflux, and involvement of deep and perforator veins was common (86.5 and 48%, respectively). In about a quarter (24%) of patients with suspected primary CVI no reflux was found in either limb on duplex scanning. Most of them (48%) had telangiectasis. Bilateral reflux was found in 71% of the patients with primary CVI. CONCLUSIONS: The clinical presentation was worse in limbs with post-thrombotic CVI than in those with a primary disease. Post-thrombotic CVI was associated with a complex pattern of reflux, affecting mostly the deep and perforator veins, whereas superficial reflux was the most common pattern in limbs with primary CVI. Therefore, surgery aiming to eliminate superficial reflux would confer only a minimal benefit in limbs with post-thrombotic CVI but would treat the majority of the limbs with the primary CVI. The high prevalence of bilateral reflux found in patients with primary CVI suggests a bilateral predisposition, which supports the hypothesis of the existence of a generalised venous disease.     

Surgery for deep venous reflux in the lower limb

Surgery for deep venous reflux (DVR) in the lower limb had displayed, for various reasons a much more limited development than arterial surgery including endovascular techniques. Importance and frequency of DVR in chronic venous disease and particularly in chronic venous insufficiency (CVI) has been fully identified only in the last 20 Years, thanks to the development of duplex-scanning. Despite its effectiveness, deep reconstructive surgery remains controversial which probably explains why this specific surgery is performed by few units worldwide. Furthermore as deep reconstructive surgery is usually combined with superficial and perforator surgery, assessment of its specific benefit is difficult. In patients with severe CVI, venous valvular reflux involves deep vein as an isolated abnormality in less than 10%, but is associated with superficial reflux or/and perforator incompetence in 46%. The most common etiology in DVR is post-thrombotic syndrome accounting for an estimated 60-85% of patients with CVI. Primary reflux is the result of structural abnormalities in the vein wall and the valve itself. A very rare cause of reflux is the absence of valves secondary to agenesis. Surgical techniques for treating DVR can be classified into two groups: those that do and those that do not involve phlebotomy. The first group includes internal valvuloplasty, transposition, transplantation, neo valve and cryopreserved allograft. The second group involves wrapping, Psathakis II procedure, external valvuloplasty (transmural and transcommissural) angioscopy assisted or not, external valve construction and percutaneous placed devices. There are some clinical features that enable distinguishing superficial venous insufficiency from deep venous insufficiency but they are not reliable enough as both are frequently combined. In addition primary reflux is difficult to identify from secondary deep reflux. INVESTIGATIONS: Duplex scanning provides both hemodynamic and anatomic information. Photoplethysmography as air plethysmography can help when superficial and deep venous reflux are combined to identify the predominant pathological component. It would seem logical to go beyond these investigations only in those patients in whom surgery for DVR may be considered. That means that the decision to continue investigations is dominated by the clinical context and absence of contraindication (uncorrectable coagulation disorder, ineffective calf pump). When surgery is considered, complementary investigations must be carried out: ambulatory venous pressure measurement and venography including ascending and descending phlebography. The goal of DVR surgery is to correct the reflux related to deep venous insufficiency at the subinguinal. But it must be kept in mind that DVR is frequently combined with superficial and perforator reflux, consequently all these mechanisms have to be corrected in order to reduce the permanent increased venous pressure. As mentioned previously, surgery results for DVR are somewhat difficult to assess as superficial venous surgery and/or perforator surgery have often been performed in combination with DVR surgery. Valvuloplasty is the most frequent procedure used for primary deep reflux. On the whole, valvuloplasty is credited with achieving a good result in 70% of cases in terms of clinical outcome defined as a freedom of ulcer recurrence and the reduction of pain, valve competence and hemodynamic improvement over a follow-up period of more than 5 years. In all series, a good correlation was observed between these three criteria. External transmural valvuloplasty does not seem to be as reliable as internal valvuloplasty in providing long-term valve competence or ulcer free-survival. In PTS, long-term results are available for transposition and transplantation. In terms of clinical result and valve competence, a meta-analysis demonstrates that a good result is achieved in 50% of cases over a follow-up period of more than 5 years, with a poor correlation between clinical and hemodynamic outcome. Results with others techniques including Psathakis II technique, neovalve and cryopreserved valves are less satisfactory. DVR surgery indications for reflux rely on clinical severity, hemodynamics and imaging: most of the authors recommend surgery in patients severe disease graded C4 and C 5-6. When superficial and perforator reflux are associated, they must be treated, for some Authors as a first step, for others shortly before DVR surgery in the same hospitalization stay. Contraindications as previously stipulated have to be kept in mind. Hemodynamics and imaging criteria: only reflux graded 3-4 according to Kistner are usually treated with DVR surgery. It is generally recognized that, to be significantly abnormal, venous refill time must be less than 12 s, and the difference between pressure at rest and after standardized exercise in the standing position must be less than 40%. The decision to operate should be based on the clinical status of the patient, not the non-invasive data, since the patient's symptoms and signs may not correlate with the laboratory findings. Indications according to etiology: the indications for surgery can be simplified according to the clinical, hemodynamic and imaging criteria described above. In primary reflux, reconstructive surgery is recommended after failure of conservative treatment and in young and active patients reluctant to wear permanent compression. Valvuloplasty is the most suitable technique, with Kistner, Perrin and Sottiurai favoring internal valvuloplasty and Raju transcommissural external valvuloplasty. In PTS, obstruction may be associated with reflux; most of the authors agree that when significant obstruction is localized above the inguinal ligament, obstruction must be treated first. Secondary deep venous reflux, mainly post-thrombotic syndrome may be treated only after failure of conservative treatment as the results achieved by subfascial endoscopic perforator surgery associated or not with superficial venous surgery are not convincing. It is recommended that this procedure might be carried out in combination with deep reconstructive surgery. The techniques to be used, given that valvuloplasty is rarely feasible, in order of recommendation, are: transposition, transplantation, neovalve and cryopreserved allograft. Patients must be informed that in PTS surgery for reflux has a relatively high failure rate. CONCLUSION: as large randomized control trials comparing conservative treatment and DVR surgery for DVR shall or should be difficult to conduct we must rely on the outcome of present series treated by DVR surgery. Analysis of those series provides recommendation grade C. Better results are obtained in the treatment of primary reflux compared with secondary reflux. Such surgery is not however, often indicated, and the procedure must be performed on specialized and high-trained centers.     

Current surgical approaches to venous hypertension and valvular reflux

Venous hypertension in the lower extremity with and without ankle ulceration can be attributed to venous outflow obstruction, venous valve incompetence with massive reflux. Compression stocking and pneumatic pump cannot provide a long-term cure of this advance stage of venous pathology and ulcer recurrence is to be expected. Definitive treatment requires the following sequential order: (1) correction of potential underlying coagulopathy (deficiency in Protein C, Protein S, anthrombin III), (2) correction of venous outflow obstruction in the pop-fem-iliac or inferior vena cava with venous bypass (balloon angioplasty of venous stenosis has disappointing long-term results because fibrocollagen is resistant to dilation), (3) correction of valve incompetence in the following order of preference: valvuloplasty, vein transposition, and valve transplantation, (4) perforator ligation and saphenous vein stripping, (5) compression stocking and pneumatic pump to enhance venous return and reduce superficial venous congestion. In nonpostphlebitic venopathy, compression stocking + pneumatic boot pump can function as a substitute for perforator ligation + saphenous vein stripping. There is high incidence of incompetence in transplated valve (53%) that can be restored with open valvuloplasty.Presented at the 36th Annual World Congress, International College of Angiology, New York, New York, July 1994     

Adequate and accurate investigation of the venous hemodynamics of the lower limb

Investigation of the deep venous system of the lower limb must mainly aim to elucidate its capabilities. Because deep venous incompetence is necessarily connected with a popliteal reflux accounted for by valvular incompetence of the popliteal vein, its presence must be clarified. Priority is given to the noninvasive Doppler ultrasound and/or duplex, and the investigation can be continued by venous pressure measurements and phlebography only when required. An operation in the deep veins is admissible only when a popliteal reflux of more than 40%, an ambulatory venous pressure of more than 60 mm Hg, a refilling time less than fifteen seconds, a venous insufficiency of more than 20%, and a patency or recanalization of the deep veins of more than 70% have been confirmed. A correlation between venous pressure and Doppler recordings has been done. In a series of 81 patients (103 limbs) operated on during the last five years, the selection for operation was made successfully only by Doppler ultrasound, as demonstrated by the results obtained after the substitute valve operation by Technique II. Presented at the 34th Annual Congress of the International College of Angiology, Budapest, Hungary, July 1992     

Indications and short term results of subfascial endoscopic perforator surgery (SEPS)

BACKGROUND: The aim of this study is to evaluate diagnostic methods, indications and surgical technique in SEPS procedure and to analyze short term results. METHODS: Eighteen patients affected by chronic venous insufficiency (CVI) have been analyzed. According to NAVS (North American Vascular Society) classification three patients were included in class 6 (C6), 3 (C5), 6 (C4), 2 (C3) and 4 (C2). From 2 to 5 selective subfascial endoscopic ligation of perforator veins, especially I and II Cockett perforator veins' were performed. In 7 cases, total stripping of the great (6) or less (1) saphenous vein was associated with SEPS procedure. After the operation, an elastic bandage of the lower limbs was performed and a medical treatment with LMVH was started. RESULTS: In 6 patients of the C2 and C3 groups, neither recurrence or pathological reflux were observed at clinical examination and at color duplex. In 12 patients of C4, C5 and C6 groups a reduction of the perimalleolar oedema was observed. In the last 3 patients, with leg ulceration, a resolution of the lesion in 2 cases, and a reduction in diameter in the last one, were observed. CONCLUSIONS: SEPS is particularly advised in those patients belonging to C5 and C6 groups, especially in presence of leg ulceration. This operations is suggested also in patients with CVI and incontinence of perforator veins detected by at color duplex. This diagnostic investigation seems to be adequate in the diagnosis of CVI and in the mapping of perforator veins of the leg.     

The role of perforating vein dissection in the treatment concept of venous ulcers--myths and evidence

Crural ulcers represent the most serious form of chronic venous incompetence (CVI). According to duplex studies superficial venous incompetence predominate in this stage of the disease, but combined refluxes of superficial and deep veins are also common. Despite a positive correlation between the number of incompetent perforators and the stage of CVI isolated incompetence of perforating veins in venous ulcers are rarely found. Additionally, only a minority of incompetent perforators depict larger reflux volumes. Therefore, doubts about a causal role of perforators incompetence in ulcer genesis are justified. According to phlebodynamometric studies the risk of crural ulcer development increases with the degree of hemodynamic compromise. Ulcer healing can only be achieved after complete normalization of ambulatory venous hypertension. In case of superficial refluxes and concomitant incompetence of perforating veins exclusion of the superficial component is sufficient to achieve this goal. Incompetent perforators normalize their function consecutively. In contrast, venous hypertension persists after exclusion of superficial refluxes in case of incompetent perforators and irreversible damage of the deep venous system. Surgical therapy studies exactly reflect the results of these hemodynamic examinations. Therefore, the role of endoscopic subfascial perforator dissection (ESPD) in the treatment of venous ulcers remains unclear. Future therapy studies should take into account that the definite role of ESPD in ulcer healing can only be examined without additional treatment of refluxes in the saphena system. Additionally, all study patients should be classified according to the CEAP nomenclature and Hach's classification of chronic compartment syndrome. Methodological differences in technique and extent of ESPD have also to be taken into account.     

Subfascial endoscopic perforating vein surgery (SEPS) for the treatment of venous ulcers

Lower extremity ulcerations that result from venous hypertension are a significant cause of disability in Western nations. Venous ulcers, highly related to lower extremity venous valvular incompetence and post-thrombotic syndrome, demonstrate a protracted course of healing with a high recurrence rate when managed conservatively. Effective treatment includes correcting the elevated lower extremity venous pressure using non-invasive (compression therapy) or invasive modalities (removal or correction of incompetent venous segments, most commonly the greater saphenous vein). Minimally invasive subfascial endoscopic perforating vein surgery, performed on an outpatient basis, allows ligation of incompetent Cockett perforating veins. Venous ulcer healing rates of 88% and infrequent wound complications have been reported using this technique. Using 5-mm cameras and trocars that are available for other endoscopic surgeries could further improve this technique; creating ports smaller than the traditional 15-mm incisions would subsequently reduce tissue disruption. In addition, the etiology of recurrent ulceration and the failure of the primary ulcer to heal are not completely understood. If these poor outcomes can be further defined, even higher rates of wound healing may be attained using this procedure. Significant efforts have been devoted to elucidating the exact mechanism of skin breakdown from venous hypertension but the pathophysiology of this process is still not understood.     

New advances in the knowledge on post-thrombotic syndrome

The real incidence of the post-thrombotic syndrome (PTS) is not known precisely, though of the most part of the variable studies, seems be deduced that it can be established a year after the deep venous thrombosis (DVT) acute of the inferior members in 17% to the 50% of the patients. Inseparably united to the venous hypertension that continues to the development of the incompetence valvular, is accompanied of a series of inflammatory reactions that include the increase in the permeability endothelial, the union of the circulating leukocytes at endothelium, the infiltration by monocytes, lymphocytes and mastocytes of the connective tissue, and the development of infiltrated tissular fibrotics and different molecular markers. To the contrary that in the DVT, we know very little about the factors that increase the risk of suffering a PTS, since the only one identified up until now it is the recurrent DVT. Currently we have different scales standardized for their your clinical diagnosis, though the Echo-Doppler is, currently, the technique not invasive of election to detect, locate and evaluate the venous disability valvular and the venous obstruction chronicle. The modern technical of image: computed tomography (CT), magnetic resonance (MR) and isotopics have a promising future, even though are found in validation phase. The phlebothropics drugs are the therapeutic election strategy for the patients with PTS in those which is not indicated the surgery or in those which this is a assisting of the medical treatment. Finally, the deep venous surgery must be reserved for all those patients that suffer from venous insufficiency serious chronicle, with meaningful venous reflux and ambulatory venous hypertension.     

Deep venous insufficiency of the lower extremities

Lower limbs chronic venous insufficiency (CVI) is a widespread pathologic condition. Prevalence of venous ulcer in Europe ranges between 0.5% and 1.0%. Venous ulceration can be due to insufficiency of the superficial system, although deep venous insufficiency is responsible for 75% of the cases. Morbidity and socio-economic costs are exceedingly high especially because of frequent recurrences. CVI recognises mainly two causes: 1) increased influx, due to arteriovenous fistulas; 2) difficult outflow usually secondary to postphlebitic or primitive valvular incompetence. The prevalence of CVI and venous ulceration is difficult to assess. Surgical treatment tends to cure the underlying hemodynamic problem. Homans in 1916 first introduced surgical treatment of CVI and venous ulceration: excision of the cutaneous lesion and ligature suprafascial of the communicating veins. Since then different various techniques have been introduced in the clinical practice: Linton in 1938 supported subfascial interruption of the perforating veins but still reported a recurrence rate of 47%. Stripping of internal saphenous vein associated with division of perforating veins is still controversial, because lacks evidence of its real effectiveness in preventing recurrences. Felder's surgical technique is preferred by some authors to Linton's technique, because of the possibility to divide and section incompetent perforating veins without a cutaneous incision in the severely diseased postphlebitic tissues. In personal experience (56 patients) treated by Felder's techniques, we reached a cutaneous ulceration healing rate of 36% has been obtained. Subfascial interruption of perforating veins under endoscopic vision associated to the stripping of the internal saphenous vein could be a valuable option in the treatment of CVI because of the shorter duration of the operation and hospital stay and lesser postoperative complications. Repair and/or replacement of deep venous valves, originally described by Kistner in 1968, could be curative of venous hypertension due to primitive valvular insufficiency (primitive or postphlebitic): the same author in 1975 reported positive results (80% at 5 years). Major advantages of indirect valvuloplastic surgical technique are: 1) venotomy is not necessary; 2) it does not introduce extraneous material in the vasal lumen; 3) clamping of the vein is avoided; 4) heparine or other antithrombotic measures are usually not necessary. Although preliminary encouraging results, subsequent clinical experiences have demonstrated that correction of the reflux of the main axial venous system alone is not curative and durable resolution of venous symptoms also depends on the concomitant correction of all incompetent perforating veins. Venous valves transplantation is theoretically good to correct the deep long reflux and to improve calf pump function, although clinical results are still limited and follow-up not prolonged enough in terms of symptoms resolution and complete ulcer healing.     

Incidence and risk factors of the post-thrombotic syndrome

Annually 1-2 in every 1000 adults will develop a deep venous thrombosis of the lower extremity. A third to half of these patients will develop the post-thrombotic syndrome (PTS). However, predicting which patients will develop the PTS remains elusive. Ipsilateral thrombosis recurrence seems to be the most important risk factor. Moreover, residual venous occlusion and valvular reflux seem to predict PTS incidence to some degree. Laboratory parameters, including d-dimers and inflammatory markers, have shown promise in predicting development of the PTS in patients and are currently under investigation. Creating a model based on all combined risk factors and patient characteristics might aid in risk stratification in individual patients.     

Results of reconstructive surgery in deep venous reflux at the subinguinal stage. Apropos of 93 interventions]

This study is a retrospective analysis of results of 93 interventions performed between 1984 and 1991 with an uniform indication: deep venous valvular reflux. Out of these 93 procedures, fifty (54%) have been undertaken in post-thrombotic syndrome (PTS), thirty-seven (40%) in deep primary vein incompetence (DPVI). Technically speaking, 46 valvuloplasties, 26 transplantations, 12 transpositions and 9 Psathakis procedures have been performed. Sixty one patients have a follow-up from 2 to 7 years (mean 44 months). In majority, valvuloplasties have been done in DPVI. Clinical and hemodynamic results in this group are good in 80% of patients controlled. Conversely transpositions, transplantations and Psathakis procedures have been undertaken essentially in PTS. Results obtained in this group are less satisfactory in terms of clinical findings and particularly in hemodynamics. Each group is analysed in details.     

Prevalence of lower extremity venous disease in inflammatory bowel disease.

AIM: Inflammatory bowel disease (IBD) has long been considered a risk factor for venous thromboembolism (VTE). Whereas most patients have persistent venous valvular dysfunction following lower extremity deep venous thrombosis (DVT), we hypothesized that patients with IBD would have an increased prevalence of valvular incompetence and changes of chronic DVT (reduced venous caliber with thickened walls) relative to patients with irritable bowel syndrome (IBS) or normal volunteers. METHODS: Subjects with confirmed IBD, clinical features of IBS or normal volunteers underwent complete, prospective duplex ultrasound assessment of their lower extremity venous vascular system. The sonographer performing the venous study was blinded to the clinical diagnosis of the patients. Valvular incompetence was graded as mild, moderate or severe based on accepted criteria. RESULTS: Eighty patients with IBD (ulcerative colitis, UC: 66; Crohn's disease: 14), 80 patients with IBS, and 80 healthy volunteers agreed to participate. One patient with UC was found to have non-occlusive chronic DVT within the left superficial femoral vein. Mild and moderate valvular incompetence was evenly distributed between the 3 groups. No patients met criteria for either acute DVT or severe venous incompetence. CONCLUSION: In patients with IBD, neither valvular incompetence nor chronic venous obstruction are over-represented compared to patients with IBS or normal volunteers. In this prospective assessment of venous physiology by duplex ultrasound, we were not able to confirm prior reports that IBD is a major risk factor for VTE.     

Management of Varicose Veins From Chronic Venous Insufficiency

Chronic venous insufficiency is a progressive disease, which may require surgical intervention to prevent complications. This study was done to determine the usefulness of a high ligation with sclerotherapy to prevent the return of symptoms. Duplex scanning was used to locate incompetent veins. There was no evidence of incompetent perforating or deep veins in the 322 patients who had 483 high ligations of the greater saphenous vein. Multiple phlebectomies and limited vein stripping were done for large (>20 mm) varicose veins. The clinical, etiologic, anatomic and pathophysiologic (CEAP) score evaluated the severity of venous dysfunctions. Symptoms of leg aches, ankle edema, night cramps or ulceration were evaluated after 1–3 months, and then at 6–12 month intervals. Sclerotherapy of the saphenous vein, using a sodium tetradecyl sulfate solution from 0.1–3.0%, was done if there was no significant improvement of a non-healing ulcer or the recurrence of symptoms. Compression hose, 30–40 mm Hg, was prescribed unless contraindicated by arterial occlusive disease, acute deep vein thrombosis or severe congestive heart disease. After the high ligation, symptoms improved in 212 limbs, were unchanged in 187 limbs and became worse in 84 limbs. After sclerotherapy in 264 limbs, 237 limbs improved, 21 remained unchanged and six became worse. Patients who have varicose veins from superficial venous incompetence can achieve a good long-term outcome with the high ligation procedure. However, it is important to control venous reflux and the related symptoms with sclerotherapy as needed.     

Anatomic and hemodynamic changes in the venous vascular bed in the lower extremities with chronic venous insufficiency

The authors paid attention to revealing as precisely as possible anatomical and haemodynamic conditions in venous vascular bed in the course of ultrasonographic examination of 309 lower extremities with clinical manifestations of chronic venous insufficiency (CVI). A combined reflux in the superficial and deep venous system (53.7%) or isolated reflux in superficial veins (25.9%) proved to be the most frequent pathogenic bases of CVI. Pathophysiology of varices was mostly based on the venous reflux and the primary idiopathic CVI was mostly present (98.1%). The post-thrombotic partial obstruction of the deep venous system (post-thrombotic venous changes on the walls) was demonstrated exceptionally (1.9%). A high coincidence of reflux in the deep and superficial venous system points out to s.c. secondary reflux in the deep veins originating on the basis of primary reflux in the large or small saphena. An attempt was made to clarify, whether the development and frequency of incompetent perforators is directly connected with the presence and seriousness of reflux in the large and small saphena. The presence and severity of large saphena insufficiency does not univocally indicate the presence of dilated or insufficient perforators on the medical side of the crus, where these anastomoses are present most frequently. The large saphena is a long vein typically suffering from segmental insufficiency, i.e. reflux affecting a certain portion, whereas other parts of the vein may be fully competent. Anatomical venous variability and abnormalities on lower extremities were demonstrated in every fifth extremity (62 extremities, 20.1%). Most of them concerned large saphena (39 extremities, 62.8%), small saphena being second (15 extremities, 25.2%). Other anatomical deviations occurred sporadically as solitary findings. In the large saphena, duplication was present most frequently (54.8%). Insufficient variable superficial veins and anatomical venous anomalies were mostly not the only pathogenic basis of CVI, but were predominantly associated with insufficiently in the area of deep veins and perforators (84%). In our cohort there were altogether 55 extremities (17.8%) after the operation on superficial venous system, where relapses of varices were found. The causes of post-operation relapse of varices may be divided into three groups: 1. insufficiency of the large saphena, 2. insufficiency of the small saphena and 3. insufficiency of the deep veins. A combined simultaneous insufficiency in several venous systems was found most frequently (27 extremities, 49.1%). Even though the reflux in the deep veins was demonstrated in 50.9% of these extremities, a combination with the reflux in superficial veins and perforators (49.1%) was present with the exception of one case of isolated insufficiency. The insufficiency of the large and small saphena was clearly the leading single causes (15 extremities, 27.3%) of varix relapses. The patients should never be operated on the venous system of lower extremities without previous detailed ultrasonographic examination. It is the only way to increase probability of the operation success and to decrease the risk of relapses of CVI manifestations.     

Improvement of microcirculation and healing of venous hypertension and ulcers with Crystacide. Evaluation of free radicals,laser Doppler flux and PO2. A prospective-randomized-controlled study

In 20 patients with chronic venous insufficiency and venous hypertension associated with ulcerations, the effects of a new compound, applied onto the skin (Crystacide) were assessed in a randomized, controlled study. Duplex scanning was used to assess the presence of venous obstruction and incompetence, and microcirculatory methods were used to assess and quantify venous microangiopathy and to follow up subjects after local treatment with Crystacide. Laser Doppler flowmetry (LDF) was used to assess skin perfusion in association with transcutaneous (tc) partial pressure of oxygen (PO2) measurements. Local plasma free radicals (PFR) were evaluated in the area surrounding the venous ulcer, with the D-Rom test. Crystacide was applied around and on the ulcer for 10 days. Crystacide was more effective than the control treatment: PO2 was increased, PFR and LDF were decreased (flux increase is associated with venous hypertension), and the ulcer area was significantly smaller at 10 days in the Crystacide group in comparison with the placebo group (p<0.05). In conclusion, in venous ulcerations, local treatment with Crystacide (10 days) improves the microcirculation and decreases skin free radicals improving healing.     

Valve repair at the level of the sub-inguinal deep venous plexus. Gadget technique or efficacious surgery?]

Between 1988 and 1990, the authors performed 35 valvuloplasties for major reflux syndrome involving the sub-inguinal deep venous system. Twenty two patients with a mean follow-up period of 23 months (1 year--3 years) were reviewed clinically and hemodynamically. Only one of the 10 patients with a chronic ulcer had developed a recurrence. This concerned the only postoperative thrombosis seen in this series. Results from a hemodynamic standpoint were as follows: Reflux evaluated preoperatively was Kistner type 4 with a popliteal venous reflux index (VRI) with a mean grade of 1.1. Postoperative evaluation (Duplex-Scan) showed the absence of reflux below the valvuloplasty in 86 p. cent of cases and VRI was normalised (less than 0.50) to the same extent. Mean venous filling time (PPG, peripheral pressure gradient measurement) after application of a supra-malleolar tourniquet was 8" (-8n + 4) preoperatively. It became normal in 13 patients and improved in 8 (mean of 82 p. cent). The results of valvuloplasty in this series confirm those published by other teams. They are notably superior to those offered by transposition and transplantation procedures. Unfortunately, this effective technique can only rarely be used in post-thrombotic syndromes and is useful essentially in Primary Deep Valve Insufficiency.     

Late results after venous valve repair

Seventeen patients (18 extremities) with primary deep venous insufficiency underwent femoral vein valve repair. Prior to the valvuloplasty the superficial and perforator systems were treated surgically. Dynamic venous pressure measurement and Doppler examination were done for late objective assessment of the valve repair. At early follow-up the reconstructed valves were competent, and all patients showed symptomatical improvement. Significant improvement in pressure reduction and recovery time was observed at postoperative venous pressure measurements. Good or excellent long-term results were obtained in 67% of the extremities after two to five years. Late recurrence of symptoms and incompetence of the reconstructed valve occurred in five extremities. Valve repair may offer good long-term results, but further studies are required to assess the appropriate place of this procedure in the treatment of primary deep venous insufficiency.     

Conception of the venous hemodynamics in the lower extremity

Contradictory reports on the significance of several hemodynamic phenomena, such as femoral vein incompetence and incompetent calf perforators, impede orientation in venous hemodynamics. Venous pressure difference arising between the popliteal and the posterior tibial vein during the activity of the calf muscle venous pump was reported for the first time about 50 years ago, but regrettably, this important discovery continues to be unrespected. The venous pressure difference has since been termed ambulatory pressure gradient and seems to be the key factor triggering the venous reflux in the lower limb as well as the process leading to varicose vein recurrence. On the other hand, simultaneous recordings of the mean venous pressure in the posterior tibial and long saphenous veins demonstrated that the pressure curves have been identical at rest, during ambulation, and in the recovery period, a finding typical of conjoined vessels. Bidirectional flow within calf perforators taking place both in healthy subjects and in patients with varicose veins enables a quick equilibration of pressure changes between deep and superficial veins of the lower leg. Reflux disturbing the venous hemodynamics is in various degrees dependent on the quantity of retrograde flow; abolition of reflux restores normal venous hemodynamics. Reflux in superficial veins, if large enough, may cause the most severe form of chronic venous insufficiency. Femoral vein incompetence and incompetent calf perforators per se do not produce ambulatory venous hypertension and do not cause hemodynamic disturbance. This study discusses the controversial issues, tries to define and appraise the principal hemodynamic phenomena (ambulatory venous hypertension, ambulatory pressure gradient, venous reflux, superficial and deep vein incompetence, incompetent perforators), mentions a possible relation between deep vein incompetence and varicose veins, and attempts to present, based on proved facts, a comprehensive picture of the venous hemodynamics in the lower extremity.