Autologous platelet‐rich fibrin matrix as cell therapy in the healing of chronic lower‐extremity ulcers

A novel autologous platelet‐rich fibrin matrix membrane (PRFM) was assessed for the ability to facilitate healing in patients with chronic lower‐extremity ulcers. Preliminary data are presented from a prospective trial (n=21). Twelve patients were identified with 17 venous leg ulcers (VLU) and nine bearing 13 nonvenous lower‐extremity ulcers. Before enrollment, the patients were evaluated for vascular status and received appropriate surgical intervention to optimize arterial and venous circulatory status. None of the ulcers had responded to a variety of standard treatments from 4 months to 53 years. Initial ulcer size ranged from 0.7 to 65 cm² (mean, 11.2 cm²). Each PRFM‐treated patient received up to three applications of either a 35 or 50 mm fenestrated membrane, depending on initial ulcer size. The primary endpoints were percent and rate of complete closure as measured by digital photography, computerized planimetery, and clinical examination. Patients were followed weekly for 12 weeks with a follow‐up visit at 16 weeks. At each 4‐week interval, the extent of healing was assessed, and those patients with >50% reduction in wound area were allowed to continue to complete closure. Patients with <50% closure received repeated applications. Complete closure was achieved in 66.7% of the VLU patients (64.7% of treated ulcers) in 7.1 weeks (median, 6 weeks) with an average of two applications per patient. Forty‐four percent complete closure was seen with non‐VLU patients (31% of treated ulcers). From the results of this small‐scale pilot study, PRFM shows significant potential for closing of chronic leg ulcers.     

A randomized,controlled, double‐blind prospective trial with a Lipido‐Colloid Technology‐Nano‐OligoSaccharide Factor wound dressing in the local management of venous leg ulcers

Venous leg ulcers (VLUs) are the most prevalent chronic wounds in western countries with a heavy socioeconomic impact. Compression therapy is the etiologic treatment of VLU but until now no wound dressing has been shown to be more effective than another. The aim of this study was to assess the efficacy of a new dressing in the management of VLU. Adult patients presenting a noninfected VLU and receiving effective compression therapy were enrolled in this randomized, controlled, double‐blind trial. The VLUs were assessed every 2 weeks for 8 weeks. The primary study outcome was the relative Wound Area Reduction (WAR, in %), and the secondary objectives were absolute WAR, healing rate, and percentage of wounds with >40% surface area reduction. One hundred eighty‐seven patients were randomly allocated to treatment groups. Median WAR was 58.3% in the Lipido‐Colloid Technology‐Nano‐OligoSaccharide Factor (TLC‐NOSF) dressing group (test group) and 31.6% in the TLC dressing group (control group) (difference: ?26.7%; 95% confidence interval: ?38.3 to ?15.1%; p = 0.002). All other efficacy outcomes were also significant in favor of the TLC‐NOSF dressing group. Clinical outcomes for patients treated with the new dressing are superior to those patients treated with the TLC dressing (without NOSF compound), suggesting a strong promotion of the VLU healing process.     

Surgical correction of recurrent venous ulcer

Seventy-six limbs from 46 patients with comparable superficial and deep venous valve incompetence underwent surgical correction for recurrent venous ulcers of the leg that were refractory to various modes of nonsurgical and surgical treatments. A follow-up of 10 to 73 months (mean = 37 months), revealed the venous ulcer healed with perforator ligation and saphenous vein stripping in 14 of 33 (44%), stripping plus valvuloplasty 17 of 21 (80%), stripping plus vein transposition 11 of 14 (78%) and stripping plus valve transplantation 6 of 8 (75%). In patients with incompetent deep venous valve and perforators, the disassociation of the superficial from the deep venous system (stripping) plus correction of the deep venous valvular incompetence (valvuloplasty, transposition or valve transplant) produced superior results in the treatment of recurrent venous ulcer when compared to perforator ligation and saphenous vein stripping alone (p less than 0.005). Adjunctive usage of elastic stockings and intermittent compression pneumatic boots in the perioperative period was helpful in controlling leg swelling and promoting wound healing.     

冷光源引导下泡沫硬化剂注射小腿曲张浅静脉在下肢静脉溃疡治疗中的应用探讨

目的探讨冷光源引导下泡沫硬化剂注射小腿曲张浅静脉联合腔镜深筋膜下交通支静脉离断术(SEPS)及大隐静脉高位结扎抽剥术治疗下肢交通静脉功能不全所致的静脉溃疡中的作用效果。 方法选取2012年6月至2013年5月就诊的42例(46条患肢)小腿交通静脉功能不全合并浅静脉曲张的静脉溃疡患者,行SEPS术及大隐静脉高位结扎抽剥术,并在SEPS术的冷光源引导下行小腿曲张静脉泡沫硬化剂注射术。 结果共注射263条曲张浅表静脉。随访期间所有患者静脉溃疡均愈合。9例患者的9条下肢(9/46,19.57%)在术后4周内出现局部疼痛,口服止疼药可缓解。22例患者的24条下肢(24/46,52.17%)共46条静脉(46/263,17.49%)在术后1 ~ 2周出现沿治疗曲张静脉行程的黄褐色色素沉着,于3 ~ 6个月内自行消失。3例患者3条下肢(3/46,6.52%)共11条静脉(11/263, 4.18%)在治疗后1周出现沿曲张静脉分布的红、热、痛和压痛,诊断为浅表性静脉炎,外用多磺酸黏多糖乳膏后缓解。经过注射的263条曲张静脉中,245条(245/263,93.16%)达到治疗成功标准,18条(18/263,6.84%)达到部分成功标准,无一条静脉未成功注射。 结论冷光源引导下的小腿曲张静脉泡沫硬化剂注射联合SEPS术及大隐静脉高位结扎抽剥术是良好的治疗交通静脉功能不全所致静脉溃疡的方法,其长期作用效果有待进一步观察。     

A real‐world experience with the bioactive human split thickness skin allograft for venous leg ulcers

Data collected from standardized clinical practices can be valuable in evaluating the real‐world therapeutic benefit of skin substitutes in the treatment of venous leg ulcers (VLU). Utilizing such a dataset, this study aimed to validate the effectiveness of a bioactive human split‐thickness skin allograft for the treatment of VLU in the real‐world setting and to understand how certain variables impacted healing rates. From a pool of 1474 VLU treated with allograft, 862 ulcers in 742 patients were selected from a large wound EMR database and analyzed. All patients received standard wound care prior to allograft application. Impact of ulcer duration, number of applications, ulcer size, and time to application were analyzed. The VLU, on average, were of 189 days duration with a mean ulcer size of 19.3 cm². During treatment, 70.7% of wounds healed, with an average time to closure of 15 weeks (SD = 14.1 weeks). The percentage of VLU less than one‐year duration that healed was significantly higher (72.3%) than the percentage of VLU with duration of greater than 1 years (51.5%) ( χ² = 18.17 ; P < .001). Ulcers less than 10 cm² in size were more likely to heal (73.9%) than those larger than 10 cm² (67.9%) ( χ² = 8.65, P = .03). VLU receiving allograft within 90 days of initial presentation are 1.4 times more likely to heal vs those receiving their first BSA application after 90 days of standard of care (95% CI: [1.05, 1.86], P = .02). Allograft used in wound clinics healed a majority of refractory VLU, even in large ulcers of long duration, which are more difficult to heal. Smaller wound, size, and shorter wound duration were associated with greater likelihood of healing. VLUs treated earlier with allograft had better healing outcomes. Clinicians may consider more aggressive and timely treatment with allograft for refractory VLU.     

Venous ulceration and saphenous ligation.

Over an 8-year period prospective series of 213 consecutive patients with venous ulceration of 232 limbs has been studied. By means of clinical, hand-held Doppler ultrasound and comprehensive ascending and descending venography examination, it was possible to identify underlying morphological abnormalities and on the basis of these to divide patients into four principal types. Type I:4%--ankle perforator incompetence alone; Type II:39%--ankle perforator and saphenous incompetence; Type III: 35%--primary deep incompetence (usually associated with perforator and saphenous incompetence); Type IV:22%--patients with postphlebitic damage. This study reports the outcome of Type II patients that have been treated by saphenous ligation alone (no perforator ligation). Healing was maintained over a mean period of 3.5 years in all but five patients. In these, other factors were shown in retrospect to be contributory to failed healing. It is concluded, therefore, that approximately 40% of venous ulcers can be ascribed to a combination of incompetence of saphenous and ankle perforating veins and that medium-term healing can be achieved in at least 90% of these by saphenous ligation alone.     

Comparative Study of Duplex-Guided Foam Sclerotherapy and Duplex-Guided Liquid Sclerotherapy for the Treatment of Superficial Venous Insufficiency

PURPOSE: To compare the preliminary results of hemodynamic changes between duplex-guided foam sclerotherapy and duplex-guided liquid sclerotherapy. METHODS: Seventy Seven limbs in 77 patients with isolated greater saphenous vein incompetence were treated with duplex-guided sclerotherapy. Thirty Seven limbs were treated with duplex-guided foam sclerotherapy and the remaining 40 limbs were treated with duplex-guided liquid sclerotherapy. Pretreatment exam was performed using a color duplex scanner and air plethysmography. The sclerosing foam was produced by Tessari's method using 1% and 3% polidocanol. The varicose vein was injected with 2 mL of 1% polidocanol or 1% polidocanol foam, and then 1 mL of 3% polidocanol or 3% polidocanol foam was injected into the greater saphenous vein under duplex guidance. Venous obstruction and recanalization were screened by serial posttreatment duplex examination, and posttreatment air plethysmography analysis was performed 3, 6, 9, and 12 months after the sclerotherapy. RESULTS: Duplex scanning demonstrated complete occlusion in the greater saphenous vein for duplex-guided foam sclerotherapy in 25 limbs (67.6%), which was a significantly higher proportion than for the duplex-guided liquid sclerotherapy (7 limbs, 17.5%, p<0.0001). Recurrent varicose veins were found in 3 patient (8.1%) in the duplex-guided foam sclerotherapy group and 10 (25%) in the duplex-guided liquid sclerotherapy group at 1-year (p=0.048). In duplex-guided foam sclerotherapy, venous filling index values remained normal during the subsequent follow-up examinations, whereas in duplex-guided liquid sclerotherapy, venous filling index began to increase, and there was a significant difference at 6 months between duplex-guided foam sclerotherapy and the duplex-guided liquid sclerotherapy (p<0.0005). At 9 months, there was a significant difference in the residual venous fraction between the two groups, and the residual venous fraction value continued to improve in duplex-guided foam sclerotherapy (p=0.033). CONCLUSIONS: Duplex-guided foam sclerotherapy could have greater promise compared to duplex-guided liquid sclerotherapy in the treatment of superficial venous insufficiency.     

Role of endovenous laser treatment in the management of chronic venous insufficiency

Endovenous laser therapy (EVLT) is a recognized option in the treatment of uncomplicated varicose veins. This uncontrolled case series evaluates its effectiveness in the management of chronic venous insufficiency. Patients with a history of active or healed ulcers were selected for EVLT. The procedure was carried out in an outpatient setting over a period of 12 months. Assessment was carried out for evidence of ulcer healing and recurrence, long saphenous vein occlusion, and patient satisfaction at 3, 12, and 22 months. Results are expressed as means with range. EVLT was used to treat 23 limbs in 20 patients with a median age of 59 years (range 32-76) including 12 females and eight males. All patients had evidence of chronic venous insufficiency, graded at C5 or greater on the CEAP classification (C5 16, C6 7). Patients with long saphenous vein insufficiency were included, whereas those with either deep or combined deep and superficial venous incompetence were excluded. The cumulative 3-, 12-, and 22-month healing rates were 87% (20/23), 100% (23/23), and 95% (21/22), respectively. The only patient having a recurrence of ulcers at 22 months' follow-up (CEAP 6) had mid-calf perforator incompetence with recanalized long saphenous vein. Duplex scan demonstrated long saphenous vein occlusion in 100% (23/23), 96% (22/23), and 91% (20/22) at 3, 12, and 22 months, respectively. In all, 84% (16/19) of patients were satisfied with the results of treatment without any major procedure-related complication. These results demonstrate that EVLT, carried out in an outpatient setting, is effective in the treatment and prevention of chronic venous ulcers, with good patient satisfaction and no major complication.     

Ultrasound-guided foam sclerotherapy combined with sapheno-femoral ligation compared to surgical treatment of varicose veins: early results of a randomised controlled trial.

AIM: This study is a prospective randomised controlled trial comparing sapheno-femoral ligation, great saphenous stripping and multiple avulsions with sapheno-femoral ligation and ultrasound guided foam sclerotherapy to the saphenous vein. Primary end points were patient recovery period and quality of life and secondary end points frequency of complications on the two arms of the trial and the cost of the treatment. MATERIAL AND METHOD: Sixty patients with primary varicose veins due to GSV incompetence and suitable for day case surgery were randomly allocated to undergo ultrasound-guided sclerotherapy with sapheno-femoral ligation under local anaesthesia (n=30) or sapheno-femoral ligation, stripping and multiple avulsions under general anaesthesia (n=30). The study protocol included history, physical examination, assignment of CEAP class and assessment venous clinical severity score (VCSS), completion of the aberdeen vein questionnaire (AVQ) and colour duplex ultrasound. RESULTS: All treatments were completed as intended. Median time to return to normal activities was significantly reduced in the foam sclerotherapy group (2 days) compared to the surgical group (8 days) (p<0.001, Mann-Whitney). AVQ score was also significantly reduced at 3 months by 46% in the sclerotherapy group, and by 40% in the conventional surgery group (p<0.001, Wilcoxon). The time taken to complete treatment was shorter in the foam sclerotherapy plus SFJ ligation group: 45 vs. 85 min (p<0.001, Mann-Whitney). The overall cost of the procedure in the sclerotherapy group ( 672.97 pounds) was significantly less compared to conventional surgery ( 1120.64 pounds). At 3 weeks, there was no statistical difference in the complication rate between the two groups. At 3 months, median CEAP class dropped from four pre-operatively to one following treatment in both groups and the median VCSS score dropped from five to one in group one and from seven to three in group two (p<0.001, Wilcoxon test). In group one four patients (13%) had a recanalised vein which needed further sessions of foam sclerotherapy, resulting in a short-term closure rate of 87%. CONCLUSION: Ultrasound guided sclerotherapy combined with sapheno-femoral ligation was less expensive, involved a shorter treatment time and resulted in more rapid recovery compared to sapheno-femoral ligation, saphenous stripping and phlebectomies.     

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.     

Early steroid withdrawal results in improved patient and graft survival and lower risk of post‐transplant cardiovascular risk profiles: A single‐center 10‐year experience

Long‐term use of steroids results in predictable secondary effects that can lead to increased morbidity and mortality. In this study, we present 10 years worth of data of early steroid withdrawal (ESW) immunosuppression consisting of mycophenolate, sirolimus, and tacrolimus. From 2003 to 2013, 563 kidney transplant recipients were weaned off steroids prior to discharge. We compared outcomes with that of our 65 historical controls maintained on steroids. We analyzed graft and patient survival and determined the incidence of steroid‐related comorbidities such as hypertension, hypercholesterolemia, diabetes, coronary artery disease, and weight gain. Patients on ESW maintenance immunosuppression had improved patient and graft survival compared to controls. (HR: 0.23; P≤.011, 0.57; P=.026). Rates of biopsy‐proven acute rejection were not different among both groups (HR: 1.24; P=.610). Incidence of post‐transplant diabetes were reduced but not statistically significant (OR: 0.67; P=.138). Additionally, the development of hypertension (OR: 0.86, P≤.01), hypercholesterolemia (RR: 0.82; P=.027), CAD (RR: 0.43; P=.002), and >20 lbs. weight gain (RR: 0.29; P≤.01) was significantly improved over 10 years following initiation of ESW protocols. Early steroid withdrawal in renal transplant recipients results in improved patient and graft survival as well as better rates of post‐transplant comorbid conditions.     

Subfascial endoscopic perforator vein surgery in patients with post-thrombotic venous insufficiency--is it justified?

Previous results following subfascial endoscopic perforator vein surgery were reported to be worse in post-thrombotic syndrome than in limbs with primary valvular incompetence. This report comprises a larger patient cohort with longer follow-up. The goal of this study was to determine if subfascial endoscopic perforator vein surgery is justified in patients with post-thrombotic venous insufficiency. The clinical data of 91 consecutive patients who underwent subfascial endoscopic perforator vein surgery with or without superficial reflux ablation over a 7-year period from May 1993 to June 2000 were retrospectively analyzed. Fifty-four females and 37 males (median age, 53 years; range, 20-77) underwent 103 subfascial endoscopic perforator vein surgery procedures. Forty-two limbs were classified as C6 (active ulcer), 34 as C5 (healed ulcer), and 24 as C4 (lipodermatosclerosis). Thirty procedures were performed in post-thrombotic limbs. Concomitant superficial reflux ablation was performed in 74 limbs (72%); saphenous vein stripping had been previously performed in 29 (28%). Deep venous incompetence was present in 89% of limbs; 13% had venous outflow obstruction on plethysmography. Cumulative ulcer healing in post-thrombotic limbs was not significantly different from limbs with primary valvular incompetence; 30-, 60-, and 90-day healing rates were 44%, 72%, and 72% vs 39%, 70%, and 87%, respectively (p = 0.35). On univariate analysis, the presence of ulcer greater than 2 cm in diameter was associated with delayed ulcer healing (p = 0.02). Cumulative ulcer recurrence in all limbs was 4%, 20%, and 27% at 1, 3, and 5 years, respectively. Ulcer recurrence in post-thrombotic limbs was higher than in limbs with primary valvular incompetence at 1, 3, and 5 years; 16%, 47%, and 56% vs 0%, 8%, and 15%, respectively (p = 0.001). Recurrent ulcers were small, superficial, and easier to heal. Clinical improvement was significant even in post-thrombotic limbs; median clinical score decreased from 9.5 to 3 (p = 0.001), and median outcome score was +2 (mean 1.9; range, -1 to 3). Median clinical score in patients with primary valvular incompetence improved from 6 to 1.5 (p = 0.0001). Subfascial endoscopic perforator vein surgery with superficial reflux ablation promoted ulcer healing, improved clinical outcome, and resulted in a low long-term ulcer recurrence rate in limbs with primary valvular incompetence. Despite good clinical outcome in post-thrombotic limbs, ulcer recurrence was high. These results imply that the role of subfascial endoscopic perforator vein surgery with superficial reflux ablation in patients with post-thrombotic limbs continues to be controversial.     

Is the nihilistic approach to surgical reduction of superficial and perforator vein incompetence for venous ulcer justified?

OBJECTIVE: Twenty-five years ago, the senior author showed a 55% postoperative ulcer recurrence rate after open perforator ligation. Those data contributed to a nihilistic attitude toward incompetent perforating veins. Conversely, since the introduction of subfascial endoscopic perforator surgery (SEPS), we have undertaken ablation of superficial and perforator reflux as initial treatment in patients with ulcers (C6) or healed ulcers (C5). This report outlines our long-term results. METHODS: Between December 1994 and November 1999, SEPS was performed on 51 limbs in 45 patients with C5/C6 disease. Sixteen limbs underwent SEPS alone, and 35 had additional surgery on the greater saphenous vein (GSV), the lesser saphenous vein, or the tributary varicies. Data were collected according to the reporting standards in venous disease. Preoperative duplex scan of deep, superficial, and perforating veins was performed. Data were analyzed with Kaplan-Meier method, Mantel-Cox log-rank test, or t test. RESULTS: Of the 51 limbs that underwent SEPS, the GSV was stripped in 28. Twenty-nine were C6, and 22 were C5. Etiology was primary (Ep) in 25 limbs and secondary (Es) in 26 limbs. All limbs had duplex scan evidence of perforator incompetence (Ap), and deep insufficiency (A(D)) was seen in 39 cases (76%). Reflux predominated (P(R)). The clinical follow-up period was 0 to 82 months (median, 38 months). Venous disability scores improved from 9.8 before surgery to 4.2 at last follow-up (P <.05). Kaplan-Meier analysis showed 74% healing at 6 months. The presence of an ulcer more than 2 cm in diameter, secondary etiology, and SEPS without concomitant GSV stripping were associated (P <.05) with delayed healing. Among patients in whom ulcers healed or who were seen with healed ulcers, the 5-year ulcer recurrence rate was 13%. Lesser saphenous vein reflux was the only factor that correlated with increased ulcer recurrence. Deep system reflux as measured with duplex scan valve closure times did not correlate with the rate of ulcer healing or recurrence. CONCLUSION: Nihilism has no place in the management of venous disease in the 21st century. An aggressive approach to superficial and perforating vein reflux in this cohort of patients with C5 and C6 disease resulted in rapid ulcer healing and low 5-year recurrence rates. Prior saphenous vein stripping, large ulcers, and secondary etiology were associated with delayed healing. A less aggressive posture toward lesser saphenous vein reflux contributed to a higher recurrence rate in this subgroup of patients. These risk factors are useful in counseling patients as to their expected postoperative course; however, no combination of factors should a priori preclude surgical intervention in this group of patients.     

大隐静脉腔内激光消融联合泡沫硬化治疗静脉曲张性溃疡

目的观察腔内激光消融(EVLA)大隐静脉联合泡沫硬化治疗下肢静脉曲张性溃疡(VULE)的临床疗效。方法回顾性分析接受EVLA联合泡沫硬化治疗的19例VULE患者(20条患肢)的资料,并观察治疗效果。结果EVLA联合泡沫硬化治疗19例20条患肢均获成功,溃疡长径术前[(2.30±1.61)cm],术后2周明显缩小到(0.90±0.32)cm(t=10.53,P0.01),溃疡愈合时间为7天~3个月,无复发病例。结论大隐静脉EVLA联合泡沫硬化治疗VULE临床疗效好。     

Haemodynamic and clinical impact of superficial, deep and perforator vein incompetence.

OBJECTIVE: The purpose of this study was to assess the effect of venous incompetence of the deep, superficial and perforator veins combined (i.e. multi-system incompetence) on the venous haemodynamics and clinical condition of limbs with chronic venous disease (CVD). METHODS: One hundred and thirty two limbs (16-C(1); 30-C(2); 20-C(3); 25-C(4); 21-C(5); 20-C(6)) of 121 patients were studied. We excluded those with previous venous surgery/sclerotherapy, peripheral arterial disease, recent deep vein thrombosis (< or =6 months), or inability to comply with the tests. The CEAP clinical class was assessed. Duplex ultrasonography (ultrasound) enabled classification according to: the presence of superficial([S]) (+/- perforator([P])) or deep([D]) (+/-S, +/-P) reflux (>.5s); the number of incompetent venous systems (single-system([S/P/D]), dual-system([S+P/S+D/P+D]), or triple-system([S+P+D])), and the number of incompetent perforators([0/1/2/> or =3]). The amount of reflux (Venous Filling Index([VFI])); calf pump Ejection Fraction([EF]), and Residual Volume Fraction([RVF]) were studied with air-plethysmography. RESULTS: VFI in limbs with triple-system incompetence (VFI median 6.68 [IQR: 4.7-9.7]ml/s) was higher than in limbs with dual-system incompetence (4.5 [2.1-7.4]ml/s), and VFI in the latter was higher than in limbs with single-system incompetence (1.3 [0.69-2.3]ml/s)(p<0.01 Kruskal-Wallis). Although EF changes were small, RVF in limbs with triple-incompetence (39 [30-51] %) was higher than in single-system incompetence (26 [16-33] %)(p<0.01 Mann-Whitney). Limbs with superficial (+/-P) incompetence had a lower VFI (p<0.01) and RVF (p<0.02) than limbs with deep (+/-S+/-P) incompetence, and limbs with > or =2 incompetent perforator veins had a higher VFI (p<0.04) than those without perforators. All limbs with single-system incompetence were C(1-3,) whereas 78% of those with triple-incompetence were C(4-6) (p<0.01). The number of incompetent systems increased with clinical class (p<0.01). CONCLUSIONS: The frequency of incompetence of more than one venous system increased with the clinical severity of venous disease and was accompanied by a 5-fold increase in the amount of reflux and a 50% rise in the RVF. The number of incompetent perforators per limb increased with the amount of reflux. The number of incompetent venous systems (superficial, deep, perforator) and perforator veins can be assessed by duplex ultrasound giving an objective indication of the functional severity of venous disease. In this way duplex ultrasound could be used to grade venous function in clinical practice as an alternative to APG measures which are less widely available.     

DUPLEX SCANNING FOR RECURRENT VARICOSE VEINS

Background: Most studies of recurrent varicose veins have been based on the findings clinically, at operation, or on phlebog-raphy. Occasionally these findings have been compared with Doppler findings produced by hand-held continuous-wave Doppler. Duplex scanning is a more refined approach to the assessment of recurrent varicose veins. Methods: 202 patients (267 legs) have been examined consecutively for recurrent varicose veins between January 1990 and December 1995 at St George Vascular Laboratory. This was a retrospective study of some aspects and patterns of recurrence of varicose veins in this group. Results: The ratio of female to male was 3 :1. The mean age of the group was 52 years and mean time to recurrence was 13 years (1 year 95% CI). There were six patterns of recurrence accounting for 95.2% of legs. In descending order of frequency, these were: (i) the saphenofemoral junction and long saphenous vein were intact and incompetent (44.6%); (ii) an incompetent thigh perforator and long saphenous vein remained intact; there was no saphenofemoral junction (16.5%); (iii) the long saphenous vein remained intact and incompetent; there was no saphenofemoral junction (10.5%); (iv) there was an incompetent saphenofemoral junction only (9.74%); (v) there was an intact and incompetent saphenopopliteal junction alone (9.74%); and (vi) an isolated thigh perforator was incompetent, with no more proximal site of incompetence detected (4.12%). Incompetent calf perforator (69.2%) and gastrocnemius veins (9.3%) were frequently detected, but rarely existed in isolation (seven legs in total). Conclusions: Duplex scanning is an important recent adjunct to the management of recurrent varicose veins in order to define the ‘pathway of incompetence’. The saphenofemoral junction and long saphenous vein remain the key to recurrence of varicose veins. Calf perforator and gastrocnemius vein incompetence are of secondary importance in recurrent varicose veins.     

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.     

Endoscopic perforator vein division with ablation of superficial reflux improves venous hemodynamics

Purpose: Hemodynamic consequences of incompetent perforator vein interruption have not been well documented. The effects of perforator interruption, with or without ablation of superficial venous reflux, on venous function in patients with advanced chronic venous insufficiency was studied. Methods: Calf muscle pump function, venous incompetence, and outflow obstruction were assessed by means of strain-gauge plethysmography (SGP) before and within 6 months after subfascial endoscopic perforator surgery (SEPS). SEPS was performed with laparoscopic instrumentation and CO₂ insufflation. Concomitant high ligation or saphenous vein stripping was performed in 24 limbs (77%). Results: Twenty-six patients, 18 women and 8 men, with a mean age of 50 years (range, 20 to 77 years) underwent SEPS. Preoperative evaluation confirmed superficial reflux in 65% of limbs, deep venous reflux in 77% of limbs, and perforator incompetence in 97% of limbs. All limbs had advanced venous dysfunction (C3, C4, C5, C6). All active ulcers (C6, n = 12) healed after surgery (mean, 32 ± 3 days), and only 1 recurred during a mean follow-up period of 11 months (range, 1 to 43 months). Clinical score improved from 6.58 ± 0.50 to 2.19 ± 0.25 (P < .0001). Improved calf muscle pump function was demonstrated by means of postoperative SGP and was indicated by increased refill volume (RV: 0.27 ± 0.06 vs 0.64 ± 0.10 mL/100 mL tissue, P < .01). Venous incompetence also improved, as evidenced by prolonged duration to refill after exercise (T90: 7.71 ± 1.20 vs 16.71 ± 1.98 seconds, P < .001) and a decrease in RV after passive drainage (3.23 ± 0.19 vs 2.63 ± 0.15 mL/100 mL tissue, P < .01). Improved refill rate (RR) correlated with improvements in clinical scores (P < .01, r = 0.77). Conclusion: SEPS with ablation of superficial reflux improved calf muscle pump function, reduced venous incompetence, and produced excellent midterm clinical results. However, functional improvement directly related to SEPS requires further investigation. This study supports adding SEPS to ablation of superficial reflux in patients with advanced chronic venous insufficiency. (J Vasc Surg 1998;28:839-47.)     

Duplex Ultrasonography–Guided Foam Sclerotherapy of Incompetent Perforator Veins in a Patient with Bilateral Venous Leg Ulcers

BACKGROUND: Recent advances in the form of foam sclerotherapy have extended the indications for sclerotherapy in the treatment of varicose veins. OBJECTIVES: (1) To see if perforator veins can be closed by using foam sclerotherapy; (2) to evaluate whether using foam sclerotherapy for treatment of incompetent perforator veins has an influence on venous leg ulcer healing. METHODS: Incompetent perforator veins above bilateral venous leg ulcers were treated with duplex ultrasonography-guided sclerotherapy using polidocanol foam. RESULTS: After 4 days, significant improvement in the ulcers was visible; after 10 days, one ulcer had closed; and within 3 weeks, both ulcers were closed. Control duplex ultrasonography showed closed perforator veins. CONCLUSION: This case illustrates that duplex ultrasonography-guided foam sclerotherapy is an effective and minimally invasive way of treating incompetent perforator veins. The fast healing of the venous leg ulcers in this case report indicates that foam sclerotherapy could be a promising addition in the treatment of venous leg ulceration with incompetent perforator veins.