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.     

Contribution of phlebography in the surgical treatment of chronic venous insufficiency of the lower extremities

In which circumstances does a surgeon request phlebograms and which ones? What is the contribution of phlebography regarding therapeutic indications and surgical technique.     

Phlebography in chronic venous insufficiency of the lower extremities. Technic and value of different tests

Remainder of the various phlebographic procedures in chronic venous insufficiency of the lower extremities: peripheral phlebography, popliteal phlebography, femoral phlebography, varicography. The techniques and the informations they provide are presented for each one of these examinations.     

The point of view of the medical phlebologist on phlebography in chronic venous insufficiency of the lower extremities

In which cases does a medical phlebologist request a phlebography, and what type? What informations does phlebography provide and what consequences may be drawn regarding the therapeutic indications.     

Classification of chronic venous disorders of lower extremities and pelvis

Variability of hemodynamic situations in different forms and stages of chronic venous disorders of lower extremities and the pelvis as well as the mushroom growth of surgical techniques used in their treatment make the author consider the correct choice of individual treatment to be the main problem. In the first place such treatment should be directed towards adequate correction of the deep venous circulation disorders providing for elimination of the main pathogenetic factors (e.g. occlusion of the main veins, pathologic impact of the gravitational column, blood regurgitation at standing and its flotation in ambulation, arterio-venous run-off, etc.). The author has revealed a classification based on systematization of most frequently observed pathology, that allows a laconic functional and topical diagnosis and provides phlebological patients with individualized treatment.