A colour Doppler ultrasound study of venous reflux in patients with chronic leg ulcers.

OBJECTIVES: to evaluate the distribution of superficial and deep venous reflux in patients with chronic leg ulcers. MATERIALS: retrospective study of 186 patients with chronic leg ulcers (212 lower limbs). RESULTS: in 127 legs without arterial disease and a history of deep venous thrombosis (DVT), 62 (49%) had superficial, 45 (35%) had superficial and deep, and 14 (11%) had isolated deep venous reflux. In legs with a previous DVT, isolated deep venous reflux was more common (21/55, 38%) but superficial reflux, often in combination with deep reflux, still predominated (56%). CONCLUSIONS: a large part of the venous insufficiency causing venous leg ulcers is superficial and suitable for varicose vein surgery. In patients with chronic leg ulcers most reflux affects the superficial system and is potentially suitable for surgical correction.     

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.     

Postthrombotic or non-postthrombotic severe venous insufficiency: impact of removal of superficial venous reflux with or without subcutaneous fasciotomy

BACKGROUND: Severe chronic venous insufficiency is often associated with therapy-resistant or recurrent venous leg ulcers, either as a result of deep vein thrombosis (DVT)- (postthrombotic syndrome [PTS]) or superficial venous insufficiency (SVI). Frequently present dermatoliposclerosis affects the skin as well as the subcutaneous and subfascial structures, which may impact tissue pressures and compromise skin perfusion. This study was undertaken to measure tissue pressures in PTS and SVI limbs and to evaluate the impact of removal of superficial venous reflux with or without concomitant subcutaneous fasciotomy. MATERIAL: In eight patients with recurrent, therapy-resistant venous leg ulcers, due to PTS (11 limbs, 12 ulcers) and 14 patients with severe SVI (14 limbs, 14 ulcers), subcutaneous fasciotomy was performed in addition to removal of superficial reflux. They were compared with eight patients with PTS (11 limbs, 11 ulcers) and 10 patients with SVI (13 limbs, 13 ulcers) who did not have fasciotomy in addition to removal of their superficial venous reflux. Intramuscular (i.m.) and subcutaneous (s.c.) tissue pressures and transcutaneous oxygen tension (TcPO(2)) were measured prior to, immediately after, and 3 months following the surgical intervention. Healing of ulcer (spontaneous or by skin grafting) at 3 months was also observed. RESULTS: There were no statistical differences between the groups regarding gender and age distribution or ulcer age at the time of surgery. All patients had in addition to surgery compression stockings class II (30 mm Hg). The i.m. tissue pressure was higher in patients with PTS compared with SVI patients, while s.c. tissue pressure and TcPO(2) did not differ between the groups. When fasciotomy was performed, i.m. and s.c. tissue pressures decreased and TcPO(2) increased significantly. Without fasciotomy, only s.c. tissue pressure decreased first at 3 months postoperatively. In the SVI-group, i.m tissue pressure was significantly decreased at 3 months in the group without fasciotomy. CONCLUSIONS: Patients with severe chronic venous insufficiency with therapy-resistant or recurrent ulcer disease due to deep and superficial insufficiency have higher i.m. tissue pressures than patients with only superficial venous reflux, even though both groups have higher i.m. and s.c. tissue pressures compared with normal values. Eradication of all superficial reflux lowers s.c. tissue pressure, while additional fasciotomy lowers both i.m. and s.c. tissue pressures and increases TcPO(2), which seems to promote ulcer healing.     

The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic.

OBJECTIVES: accurate diagnosis is essential if patients with chronic leg ulceration are to receive optimal treatment. This prospective study describes the findings of a standardised assessment protocol and the initial management of a consecutive series of patients with chronic leg ulceration presenting to a single-visit leg ulcer assessment clinic. METHODS: between January 1993 and January 1999, a total of 555 patients (220 men and 335 women of median age 73, range 28-95 years) with 689 chronic leg ulcers were assessed. Full clinical assessment, ankle:brachial pressure index and lower limb venous duplex scan were performed according to a standardised protocol and diagnostic and management data were recorded prospectively on a computerised database. RESULTS: venous disease alone was responsible for 496 of 689 (72%) ulcers. Isolated superficial venous reflux (SVR) was identified in 52% of limbs and two-thirds of these had superficial venous surgery. Combined SVR and segmental deep venous reflux (DVR) was present in 13%, and full-length DVR was present in 33% of limbs. Nineteen (4%) limbs had deep venous stenosis or obstruction. Overall, superficial venous surgery was performed in 43% and compression bandages or hosiery alone were applied in 52% of limbs. Mixed arterio-venous ulceration was present in 100 (14.5%) limbs of which 56 had arterial revascularisation, 38 had superficial venous surgery and 23 had compression alone. Fifteen limbs with pure arterial ulceration had angioplasty (n=13) or simple dressings alone (n=2). Ulceration due to lymphoedema (n=17), mixed lymphoedema and venous reflux (n=11) and other causes (n=50) were managed by compression, dressings or skin grafting. CONCLUSIONS: a standardised protocol of clinical and duplex assessment can lead to a diagnosis in 97% of chronic leg ulcers. Duplex is essential to confirm or exclude potentially correctable venous disease and allow tailored surgical intervention for those patients who many benefit.     

Mid-term recurrence rate of incompetent perforating veins after combined superficial vein surgery and subfascial endoscopic perforating vein surgery

BACKGROUND: This study investigated the mid-term (mean, 3.7 years) clinical results and the results of duplex Doppler sonographic examinations of subfascial endoscopic perforating vein surgery (SEPS) in patients with mild to severe chronic venous insufficiency (clinical class 2-6) and assessed the factors associated with the recurrence of insufficient perforating veins (IPVs). METHODS: Eighty patients with mild to severe chronic venous insufficiency undergoing SEPS were evaluated, and duplex findings, as well as clinical severity and disability scores before and after the operation, were compared. Patients with prior deep vein thrombosis (<6 months) or prior SEPS were excluded from this study. RESULTS: There were 27 men and 53 women with a median age of 59.8 years (range, 34.3-80.0 years). The distribution of clinical classes (CEAP) was as follows: class 2, 13.1% (12 limbs); class 3, 22.8% (21 limbs); class 4, 19.6% (18 limbs); class 5, 21.7% (20 limbs); and class 6, 22.8% (21 limbs). The etiology of venous insufficiency was primary valvular incompetence in 83 limbs (90.2%) and secondary disease in 9 limbs (9.8%). Concomitant superficial vein surgery was performed in 89 limbs (95.7%). Twenty (95%) leg ulcers healed spontaneously within 12 weeks after operation, whereas one patient required additional split-thickness skin grafting. Eighteen patients had previous surgery of the great and/or short saphenous vein before SEPS. During a mean follow-up of 3.7 years, recurrence of 22 IPVs was observed in 20 (21.7%) of 92 limbs, and recurrent leg ulcers were observed in 2 (9.5%) of 21 limbs. We performed univariate and multivariate analyses to predict factors influencing the recurrence of IPVs (recurrent superficial varicosis, secondary disease, active or healed leg ulcer [C5/6], compression treatment, and previous operation). On multivariate analysis, previous surgery (P = .014) was identified as the only significant factor for the recurrence of IPVs. CONCLUSIONS: SEPS is a safe and highly effective treatment for IPVs. Within a median follow-up period of 3.7 years, only 2 of 21 venous ulcers recurred, both in patients with secondary disease. Nevertheless, we observed recurrence of IPVs in 21.7% of the operated limbs. On multivariate analysis, patients who had undergone previous surgery were found to have a significantly higher rate of recurrence.     

Comparison of descending phlebography with quantitative photoplethysmography, air plethysmography, and duplex quantitative valve closure time in assessing deep venous reflux.

To assess the role of noninvasive tests--quantitative photoplethysmography, air plethysmography, and quantitative duplex scanning, we compared a group of normal (group N, eight limbs) volunteers to patients with severe chronic venous insufficiency who were stratified according to the degree of reflux seen on the current "gold standard," descending phlebography. Group M (10 limbs) had mild (grades 0 to 2) reflux, and group S (10 limbs) had severe (grades 3 to 4) reflux as determined by phlebography. Quantitative photoplethysmography could identify normal from abnormal limbs but could not distinguish the severity of reflux. Air plethysmography was used to calculate venous filling index, ejection fraction, and residual volume fraction. Ejection fraction was the same in all groups. Venous filling index could not significantly distinguish the degree of reflux (group M vs group S) but increased as reflux increased. Residual volume fraction was considerably higher in group S. Quantitative duplex valve closure time was measured in the superficial femoral and popliteal veins, with the values added together in each limb to give a total valve closure time (TVCT). A TVCT value greater than or equal to 4 seconds correlated best with severe phlebographic reflux, with a sensitivity of 90%, a specificity of 94%, and an accuracy of 93%. This value was confirmed as the best test for venous reflux by receiver operating characteristic curve analysis. Thus in the evaluation of patients with severe chronic venous insufficiency who are candidates for phlebography and surgery, quantitative duplex measurement of TVCT gives the best noninvasive assessment of the severity of deep venous reflux.     

Patterns of reflux and severity of varicose veins in the general population--Edinburgh Vein Study.

OBJECTIVES: several studies have used duplex ultrasound to assess valvular incompetence in symptomatic patients. This cross-sectional survey was performed to determine, for the first time in a general population sample, the relationship between trunk varices and the presence of reflux in lower limb venous segments. MATERIALS AND METHODS: 1238 subjects (554 male, 684 female), aged 18-64 years, were randomly selected. The presence and severity of any trunk varices was assessed and classified into Grades 1-3; hyphenweb and reticular varices were noted. The presence or absence of reflux > or = 0.5 s in five deep and three superficial venous segments in each leg was assessed using duplex ultrasound. RESULTS: the prevalence of reflux increased in both superficial and deep segments with more severe grades of trunk varices (p< or = 0.01), except the upper SFV in women. Fifteen per cent of females showed reflux confined to the superficial system, compared with 9% of males (p< or = 0.001); 22% of males showed deep reflux, compared with 11% of females (p < or = 0.001). 71% of men and 48% of women with Grade 2-3 trunk varices had mixed deep and superficial reflux. Above-knee popliteal segments had a higher prevalence of reflux than lower SFV segments in all groups. There was no consistent relationship between the presence of hyphenweb or reticular varices and deep or superficial reflux. CONCLUSION: segmental venous reflux can be detected in the deep and superficial leg veins of subjects without trunk varices, but superficial and mixed reflux are increasingly found in subjects with more severe varices.     

Chronic venous insufficiency: clinical and duplex correlations. The Edinburgh Vein Study of venous disorders in the general population

OBJECTIVE: The objective of this study was to determine the prevalence of chronic venous insufficiency (CVI) in the general population and to correlate its clinical features with sonographically proven venous reflux. DESIGN OF STUDY: The study design was a cross-sectional survey of the general population. SUBJECTS AND METHOD: Ambulatory men and women, aged 18-64 years, were selected randomly from 12 general practices. Subjects were examined for CVI. Eight segments of the deep and superficial veins were assessed for reflux by means of duplex scanning. RESULTS: A total of 1566 subjects were screened (867 women, mean age 44.8 years; 699 men, mean age 45.8 years) of whom 124 were diagnosed as having CVI: 95, grade 1; 19, grade 2; and 10, grade 3. The age-adjusted prevalence for the whole population was 9.4% in men and 6.6% in women. Prevalence of CVI correlated closely with age and sex, being 21.2% in men >50 years and 12.0% in women >50 years. Heaviness and tension, and a feeling of swelling, aching, and itching, were significantly associated with worsening grade of CVI. CVI was significantly associated with reflux in all deep and superficial segments. The frequency of reflux in both superficial and deep segments increased with the clinical severity of disease. In 30.8% of subjects with CVI in the left leg, reflux was limited to the superficial system. CONCLUSIONS: The prevalence of CVI rises steeply with age. There is a strong correlation between venous symptoms and the presence and severity of CVI. CVI is associated in approximately one third of the subjects with incompetence limited to the superficial system and in these a good therapeutic outcome could be expected from surgery to the superficial veins. The severity of clinical features, including Basle CVI grade 1, correlates significantly with prevalence of valvular reflux in the deep and superficial systems. If leg ulcers are to be prevented by timely intervention, a better understanding of the natural history of the association between presenting features and disordered hemodynamics is required.     

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.     

Factors influencing ulcer healing in patients with combined arterial and venous insufficiency

PURPOSE: The purpose of this study was to determine the effectiveness of treatment of patients with combined arterial and venous insufficiency (CAVI), evaluate variables associated with successful ulcer healing, and better define criteria for interventional therapy.Study Design: We retrospectively reviewed the records of patients treated at four institutions from 1995 to 2000 with lower extremity ulcers and CAVI. Arterial disease was defined as an ankle/brachial index less than 0.9, absent pedal pulse, and at least one in-line arterial stenosis > 50% by arteriography. Venous insufficiency was defined as characteristic clinical findings and duplex findings of either reflux or thrombus in the deep or superficial system. Clinical, demographic, and hemodynamic parameters were statistically analyzed with multiple regression analysis and correlated with ulcer healing and limb salvage. RESULTS: Fifty-nine patients with CAVI were treated for nonhealing ulcers that had been present from 1 to 39 months (mean, 6.4 months). All patients had edema. The mean ankle/brachial index was 0.55 (range, 0-0.86). Treatment included elastic compression and leg elevation in all patients and greater saphenous vein stripping in patients with superficial venous reflux. Fifty-two patients underwent arterial bypass grafting, three underwent an endarterectomy, one underwent superficial femoral artery percutaneous transluminal angioplasty, and three underwent primary below-knee amputation. For purposes of analysis, patients were divided into four groups according to the pattern of arterial and venous disease and the success of arterial reconstruction. Group 1 consisted of 22 patients with a patent arterial graft, superficial venous incompetence, and normal deep veins. Group 2 consisted of seven patients with a patent graft, superficial reflux, and deep venous reflux. Group 3 included 22 patients with a patent graft and deep venous thrombosis (DVT), and group 4 included eight patients with an occluded arterial graft. Follow-up ranged from 2 to 47 months (mean, 21.6 months). Forty-nine patients remained alive, and 10 died of unrelated causes. During follow-up, 48 of the 56 treated arteries remained patent and eight occluded. Thirty-four ulcers (58%) healed, 18 ulcers (31%) did not heal, and 7 patients (12%) required below-knee amputation for nonhealed ulcers and uncontrolled infection. No patient with graft occlusion was healed, and 12 ulcers persisted despite successful arterial reconstruction. Twenty-one (78%) of 27 patients undergoing greater saphenous vein stripping were healed, but none of these patients had DVT. The mean interval from bypass graft to healing was 7.9 months. Thirty-two (68%) of 46 patients without prior DVT were healed, whereas only two (15%) of 13 patients with prior DVT were healed, and this variable, in addition to graft patency, was the only factor statistically significant in predicting healing (P <.05). CONCLUSIONS: Ulcers may develop anywhere on the calf or foot in patients with CAVI, and healing requires correction of arterial insufficiency. Patients with prior DVT are unlikely to heal, even with a patent bypass graft. Ulcer healing is a lengthy process and requires aggressive treatment of edema and infection, and successful arterial reconstruction. Patients with a prior DVT are unlikely to benefit from aggressive arterial or venous reconstruction.     

深静脉瓣膜修复成形术治疗下肢慢性静脉功能不全的随机对照临床研究

目的探讨深静脉瓣膜修复成形术在下肢慢性静脉功能不全治疗中的作用与疗效。方法30例双下肢慢性静脉功能不全的患者接受静脉系统手术治疗。每例2条肢体各采取不同手术方式并随机分组。1条患肢行股浅静脉外瓣膜复成形术加浅静脉手术(A组);另1条患肢仅行浅静脉手术(B组)。术后1个月和3年,利用彩超、流速剖面图彩超技术、空气体积描记仪(APG)和静脉功能不全评分等方法,比较各例2条肢体的疗效以及2组间疗效。结果全组30例患者60条肢体均为CEAP临床分级(Kistner分级)C2～C4级,经彩超和下肢静脉造影证实深静脉瓣膜功能不全返流均为Ⅲ度。术后1个月和3年随访比较,各例属于A组的患肢在静脉返流度、静脉返流量及各项指标均比属于B组患肢改善明显;A组的静脉返流量、静脉灌注指数均值与B组比较差异有统计学意义(P<0.001)。2组的静脉返流度比较差异有统计学意义(P<0.05)。3年随访时2组的射血分数和剩余容量分数均值比较差异有统计学意义(P<0.05);静脉功能不全评分均值比较差异有统计学意义(P<0.001)。结论深静脉瓣膜修复成形术可使下肢深静脉返流量明显减少,瓣膜功能明显恢复,与下肢浅静脉手术联合治疗下肢慢性静脉功能不全有更好的疗效。     

Angioscopy-assisted valvuloplasty for primary deep venous valvular insufficiency

Primary deep venous valvular insufficiency causes reflux syndrome. Angioscopy permits the surgeon not only to ascertain that venous valves have not been destroyed but to perform external valvuloplasty under visual control with the valves under pressure. We have performed angioscopy-assisted venous valvuloplasty in three men (mean age 36 years; range 30 to 38 years) and one woman (age 58 years). All four patients had class 3 disease (SVS/ISCVS classification). Descending phlebograms showed grade 3 reflux in one patient and grade 4 reflux in three patients. In all patients angioscopy-assisted valvuloplasty of the superficial femoral vein was combined with wrapping with a segment of polytetrafluoroethylene prosthesis, stripping of incompetent superficial veins, and subfascial ligation of perforating veins. Mean follow-up was 12 months (range 6 to 17 months). In three patients ulcers healed and did not recur; in the remaining patient nearly complete healing was obtained after skin grafting. In all patients ambulatory venous blood pressure improved significantly and venous filling time returned to normal (> 15 seconds). At duplex ultrasonography and descending phlebography, no residual reflux was demonstrated. At final follow-up, all repaired valves were patent and competent. Our experience demonstrates that angioscopy-assisted venous valvuloplasty combines the accuracy of valvuloplasty by means of phlebotomy and the simplicity of external valvuloplasty and thus is preferred to either of these methods.     

Venous reflux in patients with previous deep venous thrombosis: Correlation with ulceration and other symptoms

Purpose: Deep vein thrombosis (DVT) in many cases leads to chronic symptoms in the damaged leg, even though the affected veins have recanalized. The major hemodynamic defect in such recanalized veins is reflux. The incidence and extent of reflux has been studied in patients with proven DVT and correlated with concurrent symptoms.Methods: Two hundred seventeen limbs in 183 patients were examined by duplex scanning from January 1989 to October 1992. All limbs had previous DVT diagnosed by venography. Sites and extent (proximal, distal, or both) of reflux were identified by meticulous duplex scanning of the whole venous system and correlated with presenting symptoms.Results: The patients were classified into nine groups on the basis of the classification of the system involved (superficial, deep, or superficial and deep) and whether the reflux was found proximal or distal to the knee or both. Eighty-one limbs belong to chronic venous insufficiency class 1, 92 belong to class 2, and 38 belong to class 3. Reflux was confined to the deep venous system in 84 limbs (38.7%), to the superficial system in 31 (14.3%) limbs, and to both systems in 102 (47%) limbs. It was confined to proximal veins only in 48 (22.1%) limbs, distal only in 56 (25.8%) limbs and throughout the limb in 113 (52.1%) limbs. The incidence of swelling was increased by distal or a combination of proximal and distal reflux regardless of which system was involved. In limbs with superficial venous insufficiency (SVI) or deep venous insufficiency (DVI) only, the incidence of skin changes was not affected by the extent of reflux. However, in limbs with combined SVI and DVI, it was increased in the presence of reflux throughout the limb. Absence of distal reflux was associated with a low incidence of skin changes even in the presence of DVI. Ulceration increased with an increased extent of reflux in the presence of SVI. Absence of superficial reflux was associated with a low incidence, even in the presence of DVI.Conclusions: The data suggest that as far as the skin changes and ulceration are concerned, distal reflux and reflux in the superficial veins are more harmful than reflux confined to the deep veins, even when such reflux extends throughout the deep venous system. (J V ASC S URG 1994;20:20-6.)     

Optimal therapy for advanced chronic venous insufficiency

INTRODUCTION: While definitive therapy awaits level I evidence, controversy persists regarding the optimal operation for treatment of advanced chronic venous insufficiency (CVI). We propose a pragmatic approach to the correction or amelioration of venous hypertension resulting from hydrodynamic and hydrostatic venous reflux. We evaluated a strategy of balloon dissection, subfascial endoscopic perforating vein surgery (SEPS) with routine posterior deep compartment fasciotomy, including ligation and stripping of the superficial system, for use when reflux is documented at duplex ultrasound (US) scanning. METHODS: This is a cooperative, multicenter, retrospective review of 832 patients stratified by CEAP classification. The series consisted of 300 patients with C4 CVI, 119 patients with C5 CVI, and 413 patients with C6 CVI. A subset of 92 patients with C4 disease were prospectively randomized, and ambulatory venous pressure (AVP) was determined preoperatively and postoperatively. All patients underwent duplex US scanning to document reflux in the deep, superficial, and perforating venous systems. Efficacy, safety, and durability were evaluated over follow-up of 1 to 9 years (mean, 31/2 years). Uniformity was attempted by adoption of the senior author's protocol and technique through on-site preceptorship in each surgeon's operative theater. RESULTS: This technique interrupted 3 to 14 (mean, 7) incompetent perforating veins per patient. Of the 832 patients undergoing SEPS, 460 (55%) underwent saphenous vein ligation and stripping at the same operation. In 92% ulcers healed or were significantly improved within 4 to 14 weeks. In 64 (8%) patients, ulcers failed to heal or there was no benefit from the operation. Thirty-two patients (4%) experienced recurrent ulceration or skin deterioration at 6 months-2 years (mean, 15 mo). Repeat SEPS was successful in 25 of these 96 patients, and deep valve repair was successful in 4 patients. In the 92 randomized patients with C4 disease, 41 refused postoperative AVP, leaving 51 compliant patients. The SEPS group (n = 25) had significantly reduced AVP (P <.01) compared with the control group (n = 26). Complications in 825 patients were less than 3% and consisted mostly of transient neurologic disorders (eg, paradysthesia), but deep venous thrombosis occurred in 2 patients, with pulmonary embolus in 1. No operative deaths occurred. Follow-up for 1 to 9 years (mean, 31/2 years) demonstrated durability. CONCLUSION: The efficacy, safety, and durability of this operative protocol proved beneficial in our clinical experience with 832 patients during 9 years of follow-up. The SEPS subset of randomized patients with C4 disease experienced significant decrease in AVP, objectively supporting the effectiveness of reflux surgery in advanced CVI. Until definitive level I evidence is available, this operative technique is advocated as optimal therapy for CVI.     

Duplex evaluation of venous insufficiency

Duplex ultrasound is the most useful examination for the evaluation of venous valvular incompetence. Multi-frequency 4 to 7-MHz linear array transducers are typically used for this assessment of superficial and deep reflux. The examination is done with the patient standing and manual compression maneuvers are used to initiate reflux. Automatic rapid inflation and deflation cuffs may be used when a standard stimulus is needed. Cutoff values for reflux have been defined. Perforating veins must be identified and flow direction during compression recorded. When ulcers are present, duplex ultrasound is used to investigate veins of the ulcerated legs. Venous outflow obstruction is also studied by duplex ultrasound and chronic changes in deep and superficial veins following deep venous thrombosis noted. The main drawback in evaluation of chronic obstruction is inability to quantify hemodynamic significance. Anatomic variations in superficial and deep veins are common and their identification is necessary. Reporting results of duplex ultrasound studies must take into consideration the proper classification of venous disease as well as the new anatomic terms that have been accepted.     

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.     

Validation of air plethysmography,photoplethysmography, and duplex ultrasonography in the evaluation of severe venous stasis

Purpose: The purpose of this study was to validate the diagnostic capabilities of the most commonly used noninvasive modalities for evaluation of chronic venous insufficiency.Methods: Twenty limbs in 20 patients were studied with air plethysmography (APG), photoplethysmography (PPG), and duplex ultrasonography. Ten limbs (group 1) were clinically without any venous disease. Group 2 consisted of 10 limbs with severe, class 3 venous stasis. Duplex ultrasonography, complemented with Doppler color-flow imaging was used to examine the superficial and deep venous systems to identify reflux.Results: Ultrasonography identified deep venous reflux in eight of 10 limbs in group 2. Severe superficial reflux was identified in the two remaining limbs. Seven limbs with deep reflux also demonstrated severe superficial reflux. Superficial venous reflux was identified in one leg in group 1. APG accurately separated normal limbs from those with reflux. Parameters that were significantly different (p < 0.05) between the two groups were the venous filling index, (group 1 = 1.37 ± 0.16 ml/sec, group 2 = 29.5 ± 6.2 ml/sec), venous volume (group 1 = 107 ± 10.1 ml, group 2 = 220 ± 22.5 ml), ejection fraction (group 1 = 52.5% ± 2.3%, group 2 = 32.5% ± 4.6%), and residual volume fraction (group 1 = 21.4 ± 2.0%, group 2 = 52.1% ± 2.5%). PPG refill times were significantly shortened in group 2 versus those of group 1 (6.4 ± 0.89 sec vs 20.2 ± 1.1 sec). The sensitivity of PPG refill times to identify reflux was 100%, but the specificity was only 60%, whereas the sensitivity and specificity for the residual volume fraction was 100%. The venous filling index was able to identify reflux and determine whether only superficial reflux was present with a sensitivity of 100% and a specificity of 90%. The κ coefficient of agreement between duplex scanning and APG was 0.83, whereas between duplex and PPG it was only 0.47.Conclusions: APG accurately identifies limbs with and without venous reflux when compared with duplex ultrasonography. APG is a better method of evaluating clinically significant venous reflux than PPG. PPG is a sensitive method of detecting reflux, but the specificity is poor, and PPG refill times cannot accurately predict the location of reflux. The combination of APG and duplex ultrasonography provides the best means of assessing venous reflux. (J VASC SURG 1994;20:721-7)     

Chronic venous insufficiency in a chinese population: An anatomic and functional study by continuous-wave doppler and photoplethysmography

A total of 1583 limbs in 878 patients who presented with symptoms of chronic venous insufficiency of the lower limbs were examined in the vascular laboratory. The anatomic distribution of valvular insufficiency was determined by continuous-wave Doppler ultrasound and functional severity was determined by the venous refilling time (VRT) using photoplethysmography. Severity of reflux was assessed using a four-class grading scale (classes 0 to 3) based on clinical and VRT criteria. A mixed incompetence of the valves in the superficial system and the perforators was encountered in the majority of patients (44% in class 0 and 85% in class 3). Deep vein incompetence was less common and usually consisted of isolated proximal incompetence of the common femoral vein (up to 32% in class 3) or was of a mixed type (21% in class 3). Isolated distal deep vein incompetence was uncommon. Proximal femoral vein incompetence and superficial system incompetence at the saphenofemoral junction were associated with severe reflux. There was significant improvement in the VRT in patients with more severe reflux (class 2 or 3) after application of an ankle tourniquet. Symptoms of moderate to severe chronic venous insufficiency and ankle ulceration may be a result of long-standing superficial system incompetence rather than deep venous disease and may thus be amendable to simple saphenofemoral ligation and interruption of perforators.     

Correlation of clinical findings with venous hemodynamics in 386 patients with chronic venous insufficiency

Deep venous insufficiency secondary to deep valvular incompetence predominated over superficial venous insufficiency in an unselected patient population with advanced chronic venous insufficiency. Venous obstruction was uncommon (5 percent), suggesting that venous bypass surgery may have limited applicability in the management of chronic venous insufficiency. Although the majority of patients (72 percent) with stage III venous disease (ulcer) had deep venous insufficiency alone and would be potential candidates for deep valvular reconstruction, 13 percent were found to have superficial venous insufficiency alone, and the remaining 15 percent, deep venous insufficiency with a hemodynamically significant component of superficial venous insufficiency. These findings suggest that not all patients with stage III disease have altered hemodynamics on the basis of deep venous valvular incompetency. Although most stage III chronic venous insufficiency is secondary to altered deep venous hemodynamics, as demonstrated by shortened venous refill time, there is a significant group of patients with severe chronic venous insufficiency having superficial venous insufficiency alone or in combination with deep venous insufficiency (28 percent). Thus, it is imperative that those patients with superficial venous insufficiency be identified by a widely available and reproducible method, such as light reflection rheography, since they may respond to surgery of the superficial venous system alone.     

Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the North American subfascial endoscopic perforator surgery registry. The North American Study Group

PURPOSE: The safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery (SEPS) for the treatment of chronic venous insufficiency were established in a preliminary report. The long-term clinical outcome and the late complications after SEPS are as yet undetermined. METHODS: The North American Subfascial Endoscopic Perforator Surgery registry collected information on 148 SEPS procedures that were performed in 17 centers in the United States and Canada between August 1, 1993, and February 15, 1996. The data analysis in this study focused on mid-term outcome in 146 patients. RESULTS: One hundred forty-six patients (79 men and 67 women; mean age, 56 years; range, 27 to 87 years) underwent SEPS. One hundred and one patients (69%) had active ulcers (class 6), and 21 (14%) had healed ulcers (class 5). One hundred and three patients (71%) underwent concomitant venous procedures (stripping, 70; high ligation, 17; varicosity avulsion alone, 16). There were no deaths or pulmonary embolisms. One deep venous thrombosis occurred at 2 months. The follow-up periods averaged 24 months (range, 1 to 53 months). Cumulative ulcer healing at 1 year was 88% (median time to healing, 54 days). Concomitant ablation of superficial reflux and lack of deep venous obstruction predicted ulcer healing (P <.05). Clinical score improved from 8.93 to 3.98 at the last follow-up (P <. 0001). Cumulative ulcer recurrence at 1 year was 16% and at 2 years was 28% (standard error, < 10%). Post-thrombotic limbs had a higher 2-year cumulative recurrence rate (46%) than did those limbs with primary valvular incompetence (20%; P <.05). Twenty-eight of the 122 patients (23%) who had class 5 or class 6 ulcers before surgery had an active ulcer at the last follow-up examination. CONCLUSIONS: The interruption of perforators with ablation of superficial reflux is effective in decreasing the symptoms of chronic venous insufficiency and rapidly healing ulcers. Recurrence or new ulcer development, however, is still significant, particularly in post-thrombotic limbs. The reevaluation of the indications for SEPS is warranted because operations in patients without previous deep vein thrombosis are successful but operations in those patients with deep vein thrombosis are less successful. Operations on patients with deep vein occlusion have poor outcomes.