Valvular incompetence in superficial, deep and perforator veins of limbs with varicose veins

Venous valvular incompetence was investigated with Doppler technique in 296 limbs with untreated primary varicose veins. Partial or complete insufficiency of the long saphenous vein was found in 95%. Six patterns of incompetence of this vein could be distinguished. Insufficiency of the short saphenous vein was present in 15% of the limbs and perforator incompetence in 45%. Femoral and/or popliteal vein reflux was found in 20% of the limbs. In eight limbs (2.7%) with verified primary deep venous insufficiency there was a moderate or severe degree of femoral and popliteal venous reflux. Skin changes secondary to the venous disease were present in 18% of the limbs, mainly those with incompetence of perforator and long saphenous veins. Doppler investigation of varicose limbs give valuable information and can be recommended as a standard pre-treatment test.     

Valvular reflux after deep vein thrombosis: incidence and time of occurrence.

From December 1986 to December 1990, 268 patients with acute deep vein thrombosis were studied in our laboratory. From this group 107 patients (123 legs with deep vein thrombosis) were placed in our long-term follow-up program. The documentation of valvular reflux and its site was demonstrated by duplex scanning. The duplex studies were done at intervals of 1 and 7 days, 1 month, every 3 months for the first year, and then yearly thereafter. The mean follow-up time for these patients was 341 days. In addition, reflux was evaluated in 502 patients with negative duplex study results and no previous history of deep vein thrombosis or chronic venous insufficiency. In the patients with acute deep vein thrombosis, valvular incompetence was noted in 17 limbs (14%) at the time of the initial study. Reflux was absent in 106 limbs (86%). In this last group reflux developed in 17% of the limbs by day 7. By the end of the first month, 37% demonstrated reflux. By the end of the first year, more than two thirds of the involved limbs had developed valvular incompetence. The distribution of reflux at the end of the first year of follow-up was the following: (1) popliteal vein, 58%; (2) superficial femoral vein, 37%; (3) greater saphenous vein, 25%; and (4) posterior tibial vein, 18%. Reflux seems to be more frequent in the segments previously affected with deep vein thrombosis. Among cases where segments were initially affected with thrombi, after 1 year the incidence of reflux was 53%, 44%, 59%, and 33% for the common femoral vein, superficial femoral, popliteal vein, and posterior tibial vein, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Deep axial reflux, an important contributor to skin changes or ulcer in chronic venous disease

OBJECTIVE: We undertook this cross-sectional study to investigate the distribution of venous reflux and effect of axial reflux in superficial and deep veins and to determine the clinical value of quantifying peak reverse flow velocity and reflux time in limbs with chronic venous disease. PATIENTS AND METHODS: Four hundred one legs (127 with skin changes, 274 without skin changes) in 272 patients were examined with duplex ultrasound scanning, and peak reverse flow velocity and reflux time were measured. Both parameters were graded on a scale of 0 to 4. The sum of reverse flow scores was calculated from seven venous segments, three in superficial veins (great saphenous vein at saphenofemoral junction, great saphenous vein below knee, small saphenous vein) and four in deep veins (common femoral vein, femoral vein, deep femoral vein, popliteal vein). Axial reflux was defined as reflux in the great saphenous vein above and below the knee or in the femoral vein to the popliteal vein below the knee. Reflux parameters and presence or absence of axial reflux in superficial or deep veins were correlated with prevalence of skin changes or ulcer (CEAP class 4-6). RESULTS: The most common anatomic presentation was incompetence in all three systems (superficial, deep, perforator; 46%) or in superficial or perforator veins (28%). Isolated reflux in one system only was rare (15%; superficial, 28 legs; deep, 14 legs; perforator, 18 legs). Deep venous incompetence was present in 244 legs (61%). If common femoral vein reflux was excluded, prevalence of deep venous incompetence was 52%. The cause, according to findings at duplex ultrasound scanning, was primary in 302 legs (75%) and secondary in 99 legs (25%). Presence of axial deep venous reflux increased significantly with prevalence of skin changes or ulcer (C4-C6; odds ratio [OR], 2.7; 95% confidence interval [CI], 1.56-4.67). Of 110 extremities with incompetent popliteal vein, 81 legs had even femoral vein reflux, with significantly more skin changes or ulcer, compared with 29 legs with popliteal reflux alone (P =.025). Legs with skin changes or ulcer had significantly higher total peak reverse flow velocity (P =.006), but the difference for total reflux time did not reach significance (P =.084) compared with legs without skin changes. In contrast, presence of axial reflux in superficial veins did not increase prevalence of skin changes (OR, 0.73; 95% CI, 0.44-1.2). Incompetent perforator veins were observed as often in patients with no skin changes (C0-C3, 215 of 274, 78%) as in patients with skin changes (C4-C6, 106 of 127, 83%; P =.25). CONCLUSION: Continuous axial deep venous reflux is a major contributor to increased prevalence of skin changes or ulcer in patients with chronic venous disease compared with segmental deep venous reflux above or below the knee only. The total peak reverse flow velocity score is significantly higher in patients with skin changes or ulcer. It is questionable whether peak reverse flow velocity and reflux time can be used to quantify venous reflux; however, if they are used, peak reverse flow velocity seems to reflect venous malfunction more appropriately.     

Femoral venous reflux abolished by greater saphenous vein stripping

Preoperative venous duplex scanning has revealed unexpected deep venous incompetence in patients with apparently only varicose veins. Acting on the hypothesis that the deep vein reflux was secondary to deep vein dilation caused by reflux volume, the following was done. Between July 1990 and April 1993, 29 limbs in 21 patients (16 females) were examined by color-flow duplex imaging to determine valve closure by the method of van Bemmelen. Instrumentation included high-resolution ATL-9 venous interrogation using a pneumatic cuff deflation stimulus of reflux in the standing, nonweight-bearing limb. All limbs showed greater saphenous vein reflux. Twenty-nine showed superficial femoral vein reflux and of these three showed popliteal vein reflux. Duplex testing was performed by a certified vascular technologist whose interpretation was blinded as to the results of clinical examination and grading of the severity of venous insufficiency. Surgery was performed on an outpatient basis under general anesthesia using groin-to-knee removal of the greater saphenous vein by the vein inversion technique of Van Der Strict. Stab avulsion of varicose tributary veins was accomplished during the same period of anesthesia. In 27 of 29 limbs with preoperative femoral reflux, that reflux was abolished by greater saphenous stripping. In patients with popliteal reflux both femoral and popliteal reflux was abolished. Improvement of deep venous hemodynamics by ablation of superficial reflux supports the reflux circuit theory of venous overload. Furthermore, preoperative evaluation of venous hemodynamics by duplex scanning appears to provide useful pre- and postoperative information regarding venous insufficiency in individual patients.Presented at the Twelfth Annual Meeting of the Southern California Vascular Surgical Society, Coronado, Calif, September 17–19, 1993.     

Prevalence of deep venous reflux in patients with primary superficial vein incompetence

PURPOSE: This prospective study was designed to determine the prevalence of deep reflux and the conditions under which it may occur in patients with primary superficial venous reflux and absence of deep venous thrombosis (DVT). METHODS: We studied 152 limbs in 120 consecutive patients in the standing position who had superficial venous reflux with color flow duplex scanning. Limbs with documented evidence of DVT or post-thrombotic vein wall changes during the examination were studied but not included in the analysis. Limbs were divided into those that had at least reflux in the saphenofemoral, the saphenopopliteal, or the gastropopliteal junction and into those with nonjunctional reflux in the superficial and gastrocnemial veins. Peak velocity and duration of reflux were measured. To examine the recirculation theory, we tested the deep veins by occluding and refluxing saphenous veins 10 cm below the sampling site. RESULTS: Thirteen limbs in 11 patients (9%) were excluded because of previous DVT. Of the remaining 139 limbs, 106 (76%) had junctional reflux. Saphenofemoral junction was involved in 89 limbs (84%), saphenopopliteal junction in 18 (17%), and gastropopliteal junction in 7 (4%). In 33 limbs (24%), reflux was detected in the main trunk or tributaries of the saphenous veins alone with no junctional incompetence. Femoral or popliteal reflux was present in 31 limbs (22%). This reflux was segmental in 27 limbs, and it was limited in the junction in 24 limbs. The mean duration of deep venous reflux was 0.9 seconds, it ranged from 0.6 to 3.7 seconds, and it was significantly shorter than that in the superficial veins (2.6 seconds; P <.0001). In the absence of junctional reflux, the prevalence of deep venous insufficiency (DVI) was significantly lower compared with that in limbs with junctional involvement (2 of 33 vs 29 of 106; P =.038). The mean duration of deep venous reflux in these groups was comparable (0.85 seconds vs 0. 91 seconds; P =.44). Occlusion of the incompetent superficial veins reduced somewhat the duration of the deep venous reflux but did not abolish it (0.88 seconds vs 0.82 seconds; P =.072). The presence of DVI was associated with junctional reflux of high peak velocity and long duration. CONCLUSIONS: The prevalence of DVI in patients with primary superficial venous reflux and without history of DVT is 22%. However, this reflux is segmental, mainly in the common femoral vein, and is of short duration. It is associated with the presence of junctional incompetence that has a high peak velocity and long duration. These findings may explain why surgical correction of superficial reflux abolishes DVI.     

Investigation and significance of short saphenous vein incompetence.

In this study, 186 limbs with varicose veins or venous skin changes were examined using duplex ultrasonography. Limbs were classified on the basis of short saphenous or popliteal venous incompetence and the number of limbs with venous ulceration (active or healed) recorded. Short saphenous incompetence did not produce a significant increase in the incidence of ulceration, whereas popliteal reflux produced an increase in the risk of ulceration which was statistically significant when compared with limbs without reflux in these two veins (chi 2 = 4.55, P = 0.003). There was no significant difference in the proportion of limbs with concomitant long saphenous reflux between these two groups. Short saphenous reflux is not important in the pathogenesis of venous ulceration. Popliteal reflux is an important factor in the pathogenesis of venous ulceration. More attention should be paid to the surgical correction of popliteal reflux when present in limbs with venous ulceration that fail to heal by conservative measures.     

Prevalence, anatomic patterns, valvular competence, and clinical significance of the Giacomini vein

OBJECTIVE: Coursing the posterior thigh as a tributary or trunk projection of the small saphenous vein (SSV), the Giacomini vein's clinical significance in chronic venous disease (CVD) remains undetermined. This cross-sectional controlled study examined the prevalence, anatomy, competency status, and clinical significance of the Giacomini vein across the clinical spectrum of CVD in relation to the SSV termination. METHODS: One hundred eighty-nine consecutive subjects (301 limbs) with suspected CVD (109 men, 80 women; age, 18-87 years [median, 61 years]) underwent examination, clinical class (CEAP) stratification, and duplex ultrasound determination of the sites and extent of reflux >0.5 sec) and Giacomini vein's anatomy. RESULTS: A Giacomini vein was found in 70.4% of limbs (212 of 301; 95% confidence interval, 65%-75.6%). Extent, pattern, and sites of reflux in all named superficial and deep veins were evenly distributed in limbs with and without a Giacomini vein; perforator vein incompetence in thigh and calf was also balanced (all, P > .2). Giacomini vein had no effect ( P > .2) on SSV termination anatomy, displaying a similar prevalence in classes C(0-6) . In 212 limbs, either as a tributary or trunk projection of the SSV, the Giacomini vein ascended subfascially (n = 210) to the lower (8%; n = 17), middle (47.6%; n = 101), or upper (44.3%; n = 94) thigh, and terminated at the deep system (45.3%; n = 96) and/or perforated the fascia (64.2%; n = 136), to join the superficial system. Giacomini vein morphology was not affected by the SSV termination anatomy and CEAP clinical class. Incompetence was detected less often (P < .001) in the Giacomini vein (4.7%; n = 10 of 212) than in the saphenous trunks cumulatively (53.3%; n = 113 of 212). Yet the odds ratio of Giacomini incompetence was 11.94 (7 of 33 over 3 of 169) in the presence of SSV reflux, and 11.67 (6 of 23 over 4 of 179) when both the great saphenous vein (proximal, proximal plus distal) and SSV were incompetent. CONCLUSION: Found in more than two thirds of limbs, the Giacomini vein has a complex anatomy that is linked vastly to the deep or superficial veins of the posteromedial thigh, but is unaffected by the anatomy of SSV termination and CEAP clinical class. Its presence proved insignificant to the extent, pattern, sites, and clinical severity of venous incompetence, yet the Giacomini vein was far less often susceptible to reflux than the saphenous trunks were. Routine Giacomini vein investigation is not justified in view of these findings. Investigation could be considered selectively in limbs with SSV incompetence, with or without great saphenous vein incompetence, supported by the high odds of concomitant Giacomini vein reflux.     

Correction of lower extremity deep venous incompetence by ablation of superficial venous reflux

Chronic venous insufficiency which produces lipodermatosclerosis, varicosities, or ulceration, is frequently caused by superficial venous reflux and deep venous incompetence. The anatomy of venous insufficiency has been clarified with duplex ultrasound, thus allowing appropriately directed therapy. However, postoperative venous physiology in patients undergoing superficial venous ablation has been infrequently reported. This study was undertaken to document the effect of superficial venous ablation on deep venous reflux. Between April 1994 and May 1995, 45 patients were examined preoperatively with duplex ultrasound. All patients had symptomatic venous insufficiency and were found to have greater saphenous vein reflux. Clinical classification of venous insufficiency (according to the criteria of the joint councils of the vascular societies) included class I in 30 patients, class II in 12, and class III in 3. Seventeen patients (38%) had reflux in the femoral venous system in addition to superficial reflux. All patients underwent removal of the proximal greater saphenous vein in concert with multiple stab avulsions of identified varicosities. Postoperative interrogation of the venous system revealed that in 16 (94%) of 17 patients, coexistent femoral venous insufficiency completely resolved. Thus ablation of superficial venous reflux eliminated incompetence in the deep venous system in patients with combined disease. These preliminary results suggest that superficial venous incompetence may be a cause of deep venous insufficiency. Whereas alternative methods to correct deep venous insufficiency have met with limited success, it appears that saphenectomy (when combined disease is present) may be effective in correction of deep venous reflux.Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995.     

Phlebographic evaluation of nonthrombotic deep venous incompetence: new anatomic and functional aspects

The anatomy, valvular function, and reflux patterns in the deep veins of the lower extremities were studied by ascending and descending phlebography in 126 limbs with nonthrombotic deep venous incompetence. The most common patterns were isolated reflux in the superficial femoral vein (51%), and combined reflux in the superficial femoral and the deep femoral veins (44%). Isolated deep femoral vein reflux occurred in 5%. As the degree of reflux in this vein varied considerably, a grading system for classification of deep femoral vein reflux was proposed. Depending on variations in the deep femoral vein anatomy, four different patterns could be distinguished. This study demonstrated that contrast filling of the deep femoral vein during ascending phlebography may indicate the presence of reflux in this vein. Complete visualization of the deep femoral vein is a new diagnostic sign that strongly correlates (p less than 0.001) with reflux in the deep femoral vein. The mean number of valves in the superficial femoral vein was reduced with increasing degree of reflux compared with a reference group consisting of 41 extremities without reflux. The diameter of the popliteal vein was significantly increased in the presence of pathologic reflux, which may indicate that vein wall dilation is a major cause of primary nonthrombotic deep venous incompetence.     

Ambulatory venous pressure revisited

PURPOSE: The purpose of this study was to describe a method for measuring the deep venous pressure changes in the lower extremity and compare it with those obtained in the dorsal foot vein. METHODS: After cannulation of the posterior tibial vein, a catheter with a pressure transducer in its tip was inserted and placed at the knee joint level. The dorsal foot vein was also cannulated. Pressures were recorded simultaneously at both sites during toe stands and repeated with the probe in the upper, middle, and lower calf. RESULTS: The study was performed in 45 patients with signs and symptoms of chronic venous insufficiency. Duplex Doppler scanning and ascending and descending venography performed before pressure measurements revealed saphenous vein incompetence in 11 lower extremities, incompetent perforators in 11 extremities (eight were combined with saphenous incompetence), and marked compression of popliteal vein with plantar flexion in 28 extremities. No significant deep axial reflux was observed on duplex Doppler examination or descending venography. No morphologic outflow obstruction was detected. The mean deep pressure at the knee joint level fell during toe stands, -15% +/- 27 (SD), and the mean dorsal foot vein pressure drop was even more marked, -75% +/- 22 (SD). Although the exercise pressure in the dorsal foot vein decreased in all patients (range, 13-90% drop), the popliteal vein pressure increased (4-72%) in nine limbs, decreased only marginally if at all in 15 limbs (0-15%), and fell more markedly in 21 extremities (22-65%). Deep vein recovery time was considerably shorter overall as compared with the findings by the dorsal vein measurement. In the comparison of limbs with and without superficial reflux, the recovery times in the deep system were significantly shorter in limbs with superficial incompetence. CONCLUSION: Ambulatory dorsal foot venous pressure is not always accurate in detecting changes in the pressure of the tibial and popliteal veins. Although dorsal foot venous pressure may be normal, deep venous pressure may decrease to a lesser degree or even increase.     

DUPLEX ULTRASOUND ASSESSMENT OF THE VENOUS STATUS OF THE SWOLLEN LEG

Between January 1991 and December 1993, duplex ultrasound characterization of venous disease in leg swelling was studied in 214 patients (261 limbs; 167 unilateral and 47 bilateral). All patients were examined with a duplex scanner, the superficial and deep venous systems were evaluated for the presence of thrombus and valvular incompetence. Of the 261 limbs, 29 (11.1%) had deep venous thrombosis, 14 (5.4%) had superficial venous thrombosis, 66 (25.3%) had deep venous incompetence (31/66 limbs also had superficial venous incompetence), 65 (24.9%) had incompetence in the superficial veins only. and five (1.9%) had deep venous obstruction resulting from a popliteal cyst or a popliteal vein ligation. Eighty-two limbs (31.4%) had no evidence of venous obstruction or incompetence at the areas evaluated. This study showed that venous obstruction and valvular incompetence had occurred in two-thirds of swollen legs examined. Some of the venous obstructions resulted from surgically treatable diseases such as a popliteal cyst, and some of the venous disorders involved the superficial venous system only. Complete venous evaluation with duplex imaging can be very helpful in the determination of the underlying cause of the swelling.     

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.     

Mechanism of action of external compression on venous function.

Compression stockings and bandages have been shown to improve venous haemodynamics and may act by reducing venous reflux. The aim of this study was to assess the mechanism of action of compression therapy on venous function and to determine whether such treatment may correct valvular incompetence. Both lower limbs of 36 patients (median age 59 (interquartile range 45-65) years) were assessed by duplex ultrasonographic scanning. There were 17 limbs with popliteal vein reflux, 19 with long saphenous vein (LSV) reflux and 21 with short saphenous vein (SSV) reflux. A water-filled adjustable pressure cuff was applied around the knee and inflated gradually, while continuously assessing the veins for reflux using ultrasonographic imaging. The external pressure applied by the cuff was noted when reflux was abolished or when the vein was completely occluded. In four (24 per cent) of 17 popliteal veins, eight (42 per cent) of 19 LSVs and three (14 per cent) of 21 SSVs reflux was abolished before occlusion of the vein. The cuff pressures required to achieve restoration of valvular function were significantly lower than those required to occlude the veins. It is possible, in some refluxing veins, to correct valvular dysfunction by external compression therapy. Coaptation of valvular cuffs to restore valvular competence may be the mechanism of action of compression therapy in venous disease.     

深静脉瓣膜重建术治疗下肢静脉倒流性疾病

为综合评价切开瓣膜修复术、静脉瓣戴戒术和静脉外肌袢成形术三种深静脉瓣膜重建手术的适应证与疗效，对１９９２年１月～１９９６年６月收治的６２例下肢静脉倒流性疾病患者进行了临床研究。全部患者均有不同程度的浅静脉曲张及下肢酸胀感，其中肿胀３０例，足靴区色素沉着２８例，溃疡１４例。病程为１年～３０年，平均１４．６年。１４例患者采用股浅静脉第１对瓣膜戴戒术，１例患者采用股浅静脉切开瓣膜修复术，４７例患者采用月国静脉外肌袢成形术。术后平均随访２０个月，所有患者症状缓解，１４例溃疡均愈合，无一例复发。结果表明：①戴戒术和瓣膜修补术适用于深静脉瓣膜功能不全倒流Ⅰ级～Ⅱ级；②肌袢成形术适用于深静脉瓣膜功能不全倒流Ⅲ级～Ⅳ级或先天性瓣膜功能缺陷；③戴戒材料宽度应增加到２ｃｍ；④对双股静脉畸形的原发性深静脉瓣膜功能不全，应同时行双股浅静脉第１对瓣膜戴戒术。认为，对月国静脉分支较多者仍可施行月国静脉外肌袢成形术，只要术中仔细操作，同样可取得优良效果     

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.     

Comparative evaluation of duplex-derived parameters in patients with chronic venous insufficiency: correlation with clinical manifestations

BACKGROUND: Quantification of venous reflux is still a matter of debate. Our goal was to compare the duplex-derived parameters between patients with early and advanced chronic venous insufficiency (CVI), and to determine indicative parameters reflecting the progression of CVI. STUDY DESIGN: A total of 1,132 limbs in 914 patients with primary valvular incompetence were included. Clinical manifestations were categorized according to the CEAP (clinical, etiologic, anatomic, and pathophysiologic) classification, and the patients were divided into two groups: group I (those with relatively early CVI, C(1-3)E(P),A(S,D,P),P(R)) and group II (those with advanced CVI, C(4-6)E(P),A(S,D,P),P(R)). The distribution of venous insufficiency was determined, and the parameters assessed were the duration of reflux (s), the peak reflux velocity (cm/s), and the flow at peak reflux (mL/s). RESULTS: There was no notable difference in overall superficial venous reflux between the groups, and the frequency of isolated deep and perforator incompetence did not differ between the groups. The duration of reflux did not improve the discrimination power between the groups. In contrast, the peak reflux velocity had significant discrimination power at the saphenofemoral junction (p < 0.0001), the saphenopopliteal junction (p = 0.0002), in the greater saphenous vein (p < 0.0001), in the superficial femoral vein (p = 0.0041), and in the popliteal vein (p = 0.003). The peak reflux flow was significantly higher in group II at the saphenofemoral junction (p < 0.0001), the saphenopopliteal junction (p = 0.0029), in the greater saphenous vein (p < 0.0001), in the common femoral vein (p = 0.006), in the superficial femoral vein (p = 0.0005), and in the popliteal vein (p = 0.0003). CONCLUSIONS: Superficial venous insufficiency might play a major role in the development of advanced CVI. The peak reflux velocity and peak reflux volume improve discrimination power between early-stage and advanced CVI.     

Endoscopic perforating vein surgery.

Perforator incompetence, caused by primary valvular incompetence or by previous deep venous thrombosis, contributes to ambulatory venous hypertension and the development of chronic venous disease. Although the exact role and contribution of perforators to the development of ulcers are still debated, poor results of nonoperative management to prevent ulcer recurrence justify surgical attempts at perforator ligation, in addition to ablation of superficial reflux. The endoscopic technique of perforator interruption has significantly fewer wound complications than the open technique and is the preferred method for ablation of medial perforating veins. Interruption of incompetent perforators with ablation of the superficial reflux, if present, effectively and durably decreases symptoms of CVI and rapidly heals ulcers. Ulcer recurrence following correction of perforator and superficial reflux in patients with post-thrombotic syndrome is much higher than in patients with primary valvular incompetence. A prospective randomized trial is needed to define the long-term benefits of interrupting incompetent perforators in all patients with advanced chronic venous disease and which patients with post-thrombotic syndrome should undergo perforator interruption.     

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.     

The development of valvular incompetence after deep vein thrombosis: A follow-up study with duplex scanning

Purpose: Duplex ultrasonography with distal cuff deflation was used to establish the physiologic reflux duration in different segments of the deep venous system in healthy individuals, and to document the occurrence of deep vein valve incompetence in patients after deep vein thrombosis (DVT).Methods: Two hundred fifty-two vein segments in 42 legs of 21 healthy individuals and 160 deep vein segments in 27 patients with phlebographically documented DVT were examined with duplex scanning.Results: The duration of reflux in healthy subjects was significantly shorter in distal deep vein segments. Ninety-five percent of the values were less than 0.88, 0.8, 0.8, 0.28, 0.2, and 0.12 seconds, respectively, for the common femoral, superficial femoral, deep femoral, popliteal, and posterior tibial vein (at midcalf and ankle level). The 95 percentile for reflux duration in the superficial venous system was 0.5 seconds for all vein segments, regardless of the location. No significant correlation was found between the reflux peak flow velocity and reflux duration (R = 0.6). The reflux peak flow velocity is therefore not useful as a parameter of the degree of reflux. The patient group was examined with an interval of 18 to 51 months (mean 34 months) after DVT. Forty-five percent of the initially affected segments showed valve incompetence at follow-up (n = 54); only three of 40 segments initially free from thrombus showed pathologic reflux at follow-up (p< 0.01). Reflux durations in most of the incompetent vein segments were two or more times the normal value of reflux duration. The highest prevalence of valve incompetence was found in the superficial femoral and popliteal vein segment (p< 0.01). None of the patients showed valve incompetence at all levels of the deep venous system. A significant (p = 0.04) relation was found between the extent of the initial thrombosis and the number of refluxing vein segments at follow-up, but no correlation was found between the extent of initial thrombosis and the late clinical symptoms (p = 0.16); clinical symptoms could not be related to the number of incompetent vein segments.Conclusions: Duplex scanning allows a good discrimination between physiologic and abnormal reflux duration and is an important tool in the evaluation of the postthrombotic limb. Early assessment after DVT may have prognostic value in individual patients. (J VASC SURG 1994;20:1059–66.)