Prevention or reversal of deep venous insufficiency by aggressive treatment of superficial venous disease

Background

This study of patients who received either aggressive or less-aggressive treatment for superficial venous disease was undertaken to determine its effects on deep venous insufficiency (DVI).

Methods

From 1998 to 2004, we treated 1,500 consecutive patients with superficial venous disease at our outpatient care center. A total of 100 patients were available for the study; the remaining patients were not available for the complete follow-up duplex scans 6 months after therapy, irrespective of the therapeutic results. Sixty-four patients underwent aggressive therapy, which included high ligation with partial selective perforation-invagination (PIN) axial stripping of the greater saphenous vein, ambulatory stab phlebectomy of the varicose veins, and transdermal treatment of the spider veins. Thirty-six patients underwent less-aggressive treatment, which included high ligation with selective partial PIN axial stripping of the greater saphenous vein and ambulatory phlebectomy of varicose vein clusters but no spider vein treatment.

Results

Follow-up duplex scanning after aggressive treatment of superficial venous disease showed improvement or complete reversal of DVI in the majority of patients. This improvement was defined as a marked decrease in the size of the deep veins in 80% of patients and a decrease of the reflux closure time of the deep venous valves in 83% of patients. Only 28% of patients receiving less-aggressive treatment without transdermal laser therapy of the spider veins showed improvement in their reflux valve closure time; the remaining 72% were unchanged or deteriorated.

Conclusions

Aggressive treatment of superficial venous disease can prevent or even eliminate deep vein insufficiency (DVI).     

Postthrombotic syndrome after isolated calf deep venous thrombosis: the role of popliteal reflux

OBJECTIVE: The purpose of this study was to evaluate the long-term clinical and hemodynamic outcomes after isolated first-time calf deep venous thrombosis (cDVT). METHODS: This retrospective clinical study was set in an academic referral center. From 1990 to 1994, 617 patients were seen with acute DVT. This number included 82 patients with phlebographically confirmed cDVT. Of those patients, 50 attended the clinical assessment 6 to 10 years (mean, 8.4 years) after the acute event. All patients with cDVT underwent treatment with anticoagulant therapy (96% heparin and warfarin, 4% only warfarin). The duration of the heparin treatment was 4.0 to 8.0 days (mean, 6.4 days), and warfarin was given for 2.0 to 7.5 months (mean, 3.4 months). Compression stockings were used regularly (mean, 9.2 months; range, 0.25 to 64 months) in 30% of the patients after acute cDVT. The initial ipsilateral phlebograms were reevaluated to confirm the diagnosis of cDVT without popliteal involvement. The clinical assessment included evaluation of both legs according to CEAP clinical classification C0-6. Bilateral color-flow duplex scan imaging was performed to assess reflux in deep popliteal segments. Photoplethysmographic measurement of venous refilling time was conducted in both legs to observe deep reflux. RESULTS: The mean age was 57 years (range, 30 to 76 years) at the time of the clinical assessment. Cause of acute cDVT was idiopathy in 52%, coagulopathy in 2%, trauma in 10%, immobilization in 22%, and postoperative in 14% of the cases. During the follow-up period, seven recurrent DVTs (14%) were seen. In the clinical assessment, 17 legs (34%) with previous cDVT had skin changes (CEAP C4-6). No active ulcers were found. Contralaterally, the frequency of C4-6 was 10% (n = 5; P <.05). After exclusion of recurrent DVTs, the distribution of the clinical classification still remained the same. Deep popliteal reflux was detected in 20 legs (40%) with previous cDVT. Contralaterally, popliteal reflux was seen in nine cases (18%; P <.05). Plethysmography showed deep reflux in 16 legs (33%) with cDVT and in nine cases (18%) contralaterally (P >.05). A significant association was found between deep popliteal reflux and skin changes (P <.05). CONCLUSION: In the long-term follow-up, cDVT may lead to significant postthrombotic disease. Reflux in the primarily uninvolved popliteal vein is frequent and may be associated with more severe disease.     

Role of superficial venous surgery in patients with combined superficial and segmental deep venous reflux.

OBJECTIVES: superficial venous surgery heals chronic venous ulceration (CVU) in the majority of patients with isolated superficial venous reflux (SVR). This study examines the role of superficial venous surgery in patients with combined SVR and segmental deep venous reflux (DVR). METHODS: combined SVR and segmental DVR was diagnosed by venous duplex in 53 limbs in 49 patients (24 men and 25 women of median age 66, range 27-90, years). Fourteen limbs had varicose veins (CEAP class 2-4) and 39 (74%) had active CVU (CEAP class 6). Duplex ultrasound was performed before and three months after local anaesthetic superficial venous surgery. Perforator vein surgery, skin grafting and compression bandaging or hosiery were not used. RESULTS: forty-two limbs with long saphenous vein (LSV) reflux underwent sapheno-femoral disconnection, 10 with short saphenous vein (SSV) reflux underwent sapheno-popliteal disconnection and one limb with LSV and SSV reflux had sapheno-femoral and sapheno-popliteal disconnection. Segmental DVR was confined to the superficial femoral vein (SFV) in 16 limbs, below knee popliteal vein (BKPV) in 25 and gastrocnemius vein (GV) in 12 limbs. Overall, duplex demonstrated post-operative resolution of segmental DVR in 26 of 53 (49%) limbs. Resolution of segmental SFV reflux occurred in 12 of 16 (75%) limbs compared with 14 of 37 (38%) limbs with segmental BKPV or GV reflux (p=0.018). Segmental DVR resolved in 19 of 39 (49%) limbs with CVU and ulcer healing occurred in 30 of 39 (77%) limbs at 12 months with a median time to healing of 61 (range 14-352) days. Segmental DVR resolved in 14 of 30 (47%) limbs with a healed ulcer: 7 of 9 (78%) limbs with SFV and 7 of 21 (33%) with BKPV or GV reflux (p=0.046). CONCLUSIONS: these data demonstrate that in patients with combined SVR and segmental DVR, superficial venous surgery alone corrects DVR in almost 50% of limbs and is associated with ulcer healing in 77% of limbs at 12 months. These findings suggest an extended role for superficial venous surgery in the management of patients with complicated venous disease.     

Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency

BACKGROUND: Endovascular radiofrequency obliteration has been used as an alternative to conventional vein-stripping surgery for elimination of saphenous vein insufficiency. A clinical registry was established in 1998, and its mid-term results have been reported previously. This study is to demonstrate the long-term treatment outcomes and to determine the risk factors that affect treatment efficacy. METHODS: Data were collected in an ongoing multicenter, prospective registry. Patients were treated before October 2004. Clinical and duplex ultrasound follow-up was performed 1 week, 6 months, 1 year, and yearly thereafter to 5 years. Treatment efficacy and clinical improvement after the procedure were analyzed. Three types of anatomical failure were identified. Logistic regression analysis was performed to determine the existence of any significant risk factors associated with anatomical failure. Risk factors considered were age, gender, body mass index, vein diameter, and pullback speed. The impact of anatomical failure on clinical symptoms and varicose vein recurrence was also analyzed. RESULTS: There were 1,006 patients (1,222 limbs) treated, their mean age was 47.4 +/- 12.1 years, and 78.1% were female. Veins treated included 89.1% great saphenous vein above-knee segments, 1.2% great saphenous vein below-knee segments, 4.1% great saphenous vein groin-to-ankle, 4.3% small saphenous veins, and 1.3% accessory saphenous veins. Mean vein diameter was 7.5 mm, with a maximum of 24 mm. Vein occlusion rates were 87.1%, 88.2%, 83.5%, 84.9%, and 87.2%, and reflux-free rates were 88.2%, 88.2%, 88.0%, 86.6%, and 83.8% at each annual follow-up. Clinical symptom improvement was seen in 70% to 80% of limbs with anatomical failures and in 85% to 94% of limbs with anatomical success from 6 months to 5 years after the radiofrequency obliteration. Logistic regression analysis showed that catheter pullback speed (P < .0001) and body mass index (P < .0333) were risk factors for anatomical failure. Limbs that had type II and type III anatomical failures were found to be more prone to varicose vein recurrence. CONCLUSIONS: Endovascular radiofrequency obliteration of saphenous vein reflux exhibits enduring efficacy. Adequate pullback speed during the procedure should be emphasized to ensure the proper thermal dose delivery. A whole treatment strategy to address hemodynamically significant tributaries and perforators can further improve treatment outcomes. Body mass index is a risk factor for anatomical failure, indicating the impact of hemodynamic factors on disease progression and recurrence.     

Causes of severe chronic venous insufficiency

A large number of adults in this country have some form of chronic venous insufficiency and a significant percentage of these have venous ulcers. The past decade has refined understanding of leukocyte-mediated injury and has elucidated the role of inflammatory processes in the dermal pathology of chronic venous insufficiency. Understanding of these pathologic cellular functions and molecular regulation of these processes is increasing.     

Foam sclerotherapy for the treatment of superficial venous insufficiency

Foam sclerotherapy has been refined over the past decade to become a safe and effective treatment for varicose veins and venous insufficiency. Using duplex ultrasound guidance, it can be used to treat large and small varicosities, saphenous trunks, incompetent perforating veins, and venous stasis ulcerations. Serious complications are rare, and in experienced hands, efficacy rivals that of traditional surgical ligation and stripping. Disadvantages of the technique are the need in many cases for more than one treatment session, and lack of US Food and Drug Administration approval of all currently available sclerosants. Foam sclerotherapy offers advantages of low cost, quick patient recovery, and ease of use; as such, it is an important tool for modern vein treatment.     

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.)     

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.     

Evaluation of methods for detecting venous reflux. Perspectives in venous insufficiency

Using 793 limbs with nonobstructive venous reflux, we evaluated a number of techniques used for the assessment of venous reflux. The venous Doppler examination was found to be a reliable screening tool with excellent sensitivity and good specificity. Photoplethysmography was 97% sensitive in patients with ambulatory venous hypertension; however, in milder forms of reflux, it was less sensitive. The major drawback of photoplethysmography was the large number of false-positive results obtained. Ambulatory venous pressure measurement and another pressure-based technique, Valsalva-induced foot venous pressure measurement, defined overlapping but different normal and abnormal limbs. Descending venography, when performed as described by Kistner et al, was found to be a reliable tool to assess reflux with more than a 90% sensitivity. The horizontal technique of performing descending venography and nucleotide descending venographies had unacceptably low sensitivity and were abandoned. Features of venous reflux as outlined by these modern technical tools are described.     

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.     

Outpatient management of superficial venous insufficiency at a naval medical facility

Superficial venous insufficiency is common in a young, working population. It can result in disability and lost time from work because of chronic pain, inflammation, and/or ulceration. We reviewed our experience in the management of 104 patients with superficial venous insufficiency secondary to saphenofemoral and/or perforator venous incompetence. The main treatment objective was to control venous insufficiency in a manner that would allow a rapid return to duty. The technique involved ligation of the incompetent saphenofemoral junction and/or perforating veins (i.e., point ligation) under local anesthesia. Patients returned to normal duty status the day after treatment. Six weeks later any persistent disease was controlled with compression sclerotherapy. Significant morbidity included postoperative wound complications in 4% and thrombophlebitis in 14%. Objectives of treatment, with excellent functional and cosmetic results, were achieved. True recurrence was noted in 8% of patients, whereas new disease developed in only 4%; the total recurrence rate was 12%. This mode of therapy is ideally suited to outpatient management. This study demonstrates the excellent control of venous dysfunction that is achievable with the use of selective therapy based on proximal venous ligation and staged sclerotherapy.The Chief, Bureau of Medicine and Surgery, Navy Department, Washington, D.C., Clinical Investigation Program sponsored this study No. S-94-063, as required by HSETCINST 6000.41A.Veluntary informed consent of the subjects used in this research was obtained, as required by SECNAVINST 3900.39B.The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States government.     

Platelet-monocyte aggregates in patients with chronic venous insufficiency remain elevated following correction of reflux

INTRODUCTION: An increased number of circulating platelet-monocyte aggregates (PMAs) is present in patients with all clinical classes of chronic venous insufficiency (CVI). The purpose of this study was to determine whether patients with CVI maintain elevated levels of PMAs following complete surgical correction of chronic venous insufficiency. METHODS: Patients with superficial venous insufficiency and a normal deep venous system documented by duplex scan were included in the study. Venous blood was drawn from a superficial vein in the leg and an antecubital vein prior to vein stripping and again six weeks postoperatively. Control subjects without evidence of venous disease had blood drawn from an antecubital vein. Whole blood flow cytometry was used to analyze the samples for the presence of platelet-monocyte aggregates following incubation with buffer or 0.5 microM adenosine diphosphate (ADP). RESULTS: Postoperative duplex scanning demonstrated elimination of venous reflux in the superficial venous system and normal deep vein physiology in all nine patients. Preoperatively, patients with CVI had significantly elevated levels of circulating PMAs in both arm and leg samples without stimulation by an agonist compared to controls (15.2+/-1.1 and 14.3+/-1.3 vs 7.4+/-0.3 for controls, p<0.02 for each), and after stimulation by 0.5 microM ADP (33.7+/-4.7 and 34.3+/-5.2 vs 12.5+/-3.8 for controls, p<0.04 for each). There was no significant change in the number of PMAs in either patient arm or leg blood samples six weeks following correction of venous reflux by removal of the diseased veins. CONCLUSIONS: Complete correction of chronic venous insufficiency did not diminish the elevated circulating levels of platelet-monocyte aggregates. We conclude that the presence of an increased number of PMAs identified in patients with CVI is not secondary to the presence of venous reflux, but may be involved with the primary etiology of chronic venous insufficiency. This finding also suggests that a stimulus other than venous hypertension may be important in triggering the leukocyte activation seen in patients with chronic venous disease.     

Most incompetent calf perforating veins are found in association with superficial venous reflux.

PURPOSE: The indications for surgical perforator interruption remain undefined. Previous work has demonstrated an association between clinical status and the number of incompetent perforating veins (IPVs). Other studies have demonstrated that correction of IPV physiology results from abolition of saphenous system reflux. The purpose of this study was to identify which, if any, patterns of venous reflux and obstruction are particularly associated with IPV. PATIENTS AND METHODS: Two hundred thirty patients and subjects (103 men, 127 women, 308 limbs) with varying grades of venous disease were examined both clinically and with duplex ultrasound scan. The odds ratios (ORs) for the presence of IPVs were calculated for different anatomical distributions of main-stem venous reflux and obstruction. The base group are those with no main-stem venous disease. RESULTS: There were no significant associations between the proportions of limbs demonstrating IPVs and patient age or sex. The ORs for the presence of IPVs in association with other venous disease are as follows (age/sex adjusted): long saphenous vein reflux, OR = 1.86, range = 1.32-2.63; short saphenous vein reflux, OR = 1.36, range = 1.02-1.82; deep system venous reflux, OR = 1.61, range = 1.2-2.15; superficial system reflux, OR = 3.17, range = 1.87-5.4; and deep system obstruction, OR = 1.09, range = 0.51-2.33. The ORs for combinations of venous disorders were calculated. Combinations of disease produced higher odds for the presence of IPVs than those above, the highest being long saphenous vein, short saphenous vein, and deep reflux combined, OR = 6.85 (95% CI, 2.97-15.83; P =.0001). CONCLUSIONS: Although the presence of IPVs is associated with venous ulceration, the highest ORs for the presence of IPVs were found in patients with superficial disease alone or in combination with deep reflux. Many of these may be corrected by saphenous surgery alone.