A prospective randomized trial evaluating the haemodynamic role of incompetent calf perforating veins

AIM: This study was undertaken to determine the haemodynamic effect of incompetent calf perforating veins in patients with uncomplicated varicose veins and long saphenous incompetence. METHODS: Thirty-eight limbs from 35 patients were studied. All patients had uncomplicated varicose veins with both long saphenous and calf perforator incompetence on duplex ultrasonography. Patients were randomized to have incompetent calf perforators ligated or left intact, in addition to saphenofemoral junction ligation, strip of long saphenous vein to knee and stab avulsion of any visible varicosities in the leg. Patients were assessed with air plethysmography pre-operatively and 3 months postoperatively. RESULTS: Superficial venous surgery improved venous volume, venous filling index and ejection fraction in the patient cohort. No significant haemodynamic difference was demonstrated between the two groups of patients who were randomized. CONCLUSIONS: At present, the results of this study do not support the use of routine perforator ligation during superficial surgery for uncomplicated varicose veins.     

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.     

Miniincisional ligation of incompetent perforating veins of the legs

Purpose: The purpose of this study was to determine the effectiveness of a new surgical procedure for interrupting incompetent perforating calf veins in patients with recalcitrant venous ulcers.Methods: Eighteen patients with venous ulcerations in 26 limbs had incompetent perforators diagnosed by duplex scanning. All were taken to the operating room, where the fascial defects through which the perforators coursed were obliterated by a “pursestring” permanent suture placed on the leg fascia. Follow-up duplex scanning was carried out within 2 weeks of the procedure and every 6 months thereafter. The mean follow-up in this series was 22 months.Results: Initial success in obliterating the perforators was noted in 24 (92.3%) of 26 legs. Three subsequent failures occurred within 6 months for a midterm success rate of 80.7%. No wound complications or infections occurred. All ulcers healed within 6 weeks of the procedure (mean, 23 days) in the successfully treated patients.Conclusions: Miniincisional ligation of incompetent perforating veins is easy to perform and has very encouraging early results. (J Vasc Surg 1997;25:437-41.)     

Cryoperforator surgery: a new treatment of incompetent perforating veins

This study was conducted to determine the feasibility of cryoperforator surgery in the treatment of incompetent perforating veins. Fifteen patients with C2-C4 varicose disease (according to the Clinical-Etiology-Anatomy-Pathophysiology classification) were enrolled in this study. Under local anesthesia, incompetent perforating veins were treated with a duplex-guided cryoprobe. Duplex scans were performed 2 and 4 weeks after treatment. Fifteen patients with 28 incompetent perforating veins were treated with cryoperforator surgery. Distribution of the incompetent perforating veins was as follows: posterior tibial perforator, 12; paratibial perforator, 11; intergemellar perforator, 1; lateral leg perforator, 4 (range = 1-5 incompetent perforating veins per patient). Follow-up showed successful treatment of 12 incompetent perforating veins (43%). This study showed that cryoperforator surgery is feasible for treatment of incompetent perforating veins. Higher success rates could be obtained with our modified diamond-dust coated cryoprobe. Major advantages are the treatment in an outpatient setting and the possibility of treating all incompetent perforating veins, intraluminal or extraluminal.     

Prevalence and distribution of incompetent perforating veins in chronic venous insufficiency

Purpose: The purpose of this study was the investigation of the prevalence and distribution of incompetent perforating veins (IPVs) in patients with different classes of chronic venous insufficiency (CVI) as defined by the updated clinical, etiologic, anatomic, and pathologic classification (CEAP) in relation to the pattern and the extent of venous reflux. Material and methods: The study included 468 limbs of 330 subjects who ranged in age from 18 to 101 years (median, 49 years). The investigation entailed a medical history, a clinical examination, and color flow duplex imaging of the lower limb veins, which were performed by the same vascular surgeon operator. The patients were classified into 7 clinical classes according to CEAP. The superficial and deep venous systems were scanned, with an emphasis on the detection of IPVs. Venous reflux was considered abnormal when its duration exceeded 0.5 seconds. IPVs were classified as medial, posterior, and anterolateral in the upper, middle, or lower third of the thigh or calf (9 thigh and 9 calf fields). Results: The IPVs were found mainly in the medial aspect, more frequently in the middle third of calf, followed by the lower calf and the middle thigh. IPVs were rare in the lateral aspect of the thigh, the medial upper and posterior lower thigh and the posterior upper and lower calf. The prevalence of the IPVs and of deep vein incompetence increased significantly with the clinical severity of CVI (r = .95, P < .01, and r = .9, P < .01, respectively). In the limbs with a documented perforating vein (PV) incompetence, the ratios of calf-to-thigh IPVs and of superficial-and-deep (S + D) over superficial-alone (S; [S + D]/S] venous incompetence increase significantly (r = .87, P < .01 and r = .9, P < .01, respectively) with CEAP grade. The prevalence of reflux involving all systems (S + D + PV) increases significantly (r = .9, P < .01) with clinical severity. In legs with CVI of CEAP 2 to 6, reflux was invariably proximal (thigh) and distal (below knee). Conclusion: In CVI, IPVs are located predominately in the medial aspect of the lower extremity, more often in the middle third of the calf, followed by the lower calf and middle thigh. The prevalence of IPVs and their calf-to-thigh ratio increase linearly with the clinical severity of CVI. Both the prevalence of deep vein incompetence and the ratio of superficial and deep to superficial ([S + D]/S) increase linearly with CEAP classification. These findings support the significant relationship between deep venous reflux and PV incompetence, although the latter may exist in the absence of the former. In CEAP classes 2 to 6, reflux is invariably proximal and distal. Incompetence involving all systems (S + D + PV) increases in prevalence with the severity of CVI. (J Vasc Surg 1998;28:815-25.)     

下肢功能不全穿通静脉的治疗进展

下肢功能不全穿通静脉（IPV）是下肢静脉性溃疡迁延不愈和下肢静脉曲张术后复发的重要原因之一,是临床上值得探讨的热点问题。笔者简要阐述下肢IPV的发病机制,对开放性穿通静脉离断手术、筋膜下经腔镜穿通静脉离断术（SEPS）和经皮穿通静脉闭合术（PAPS）的手术方式、优缺点做一描述,并提出微创化已成为IPV手术治疗的趋势,期望为临床上治疗IPV提供借鉴。      

Endoscopic subfascial sectioning of incompetent perforating veins in treatment of primary varicosis

Subfascial elimination of incompetent perforating veins is the most effective therapeutic principle in the treatment of trophic skin disorders associated with varicosis. A recently developed endoscopic technique allows accurate sectioning of perforating veins with direct observation of the veins and minor trauma. From November 1986 to July 1991 endoscopic sectioning of perforating veins was performed in 72 patients (103 legs). The most frequently transected perforating veins were Cockett's veins (n=219), 24 cm perforating veins (n=83), and Boyd's perforating veins (n=82). Postoperative delayed wound healing was observed in 3 (2.9%) legs with pronounced trophic skin disorders in the lower extremities. Two patients complained of dysesthesia in the area of distribution of the sural nerve. Further complications recorded were extended subcutaneous hematoma in 6 (5.8%) legs and postoperative dysesthesia in the area of distribution of the saphenous nerve in 10 (9.7%) legs. At follow-up examination (mean 27 months postoperatively) clinical investigation and Doppler sonography showed newly formed incompetent perforating veins in only 2 lower legs. Radiography at follow-up revealed one incompetent Dodd's perforating vein in 1 leg, which was the starting point of pronounced recurrent varicosis in the lower leg. After an average follow-up of >2 years, we recorded the occurrence of new varices in 9 lower legs. Staging of chronic venous incompetence showed an upward trend ranging from change to a more favorable stage to complete cure. Findings were unchanged in only 10% of the patients. There was no case of postoperative aggravation.

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Resumen La ligadura subfascial de las venas perforantes incompetentes constituye el método terapéutico más eficaz en el tratamiento de las alteraciones tróficas de la piel secundarias a várices. Una técnica endoscópica recientemente desarrollada hace posible la sección precisa de las venas perforantes mediante la observación directa de las venas y con mínimo trauma. La sección endoscópica de las venas perforantes fue realizada en 72 pacicentes (103 extremidades) en el período noviembre 1986 a julio 1991. Las venas más frecuentemente seccionadas fueron las venas de Crockett (219), las perforantes a 24 cm (83) y las perforantes de Boyd (82). Se registró cicatrización retardada en tres piernas (2.9%) que presentaban marcadas alteraciones tróficas. Dos pacientes se quejaron de disestesia en el área de distribución del nervio sural. Otras complicaciones registrada fueron hematoma subcutáneo en 6 piernas (5.8%) y disestesia postoperatoria en el área de distribución del nervio safeno en 10 piernas (9.7%). En el seguimiento de control (período de seguimiento de 27 meses) el examne clinico y la sonografía Doppler demostró neoformación de venas perforantes incompetentes en sólo dos piernas. La radiografía de control reveló una vena perforante, lo cual significó el punto de partida de varicosidades recurrentes severas. En un período promedio de seguimiento de más de dos años, registramos el desarrollo de nuevas várices en nueve piernas. La estadifición de la incompetencia venosa crónica demostró una tendencia ascendente, desde el estadio de alteración hacia un estadio más favorable y hasta la curación completa en 90% de los casos. Los hallazgos permanecieron estacionarios en sólo 10% de los pacientes. No hubo casos de empeoramiento postoperatorio.

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Résumé L'ablation chirurgicale sous-aponévrotique des veines perforantes incompétentes est le traitement le plus efficace des troubles trophiques des varices des membres inférieurs. Une nouvelle technique endoscopicue a été dévelopée pour sectionner les veines perforantes sous contrôle de la vue et avec un minimum de traumatisme. Entre Novembre 1986 et Juillet 1991, on a réalisé cette technique chez 72 patients (103 jambes). Les veines le plus souvent intéressées étaient la veine de Cockett (n=219), la veine perforante de 24 cm (n=83), et la veine de Boyd (n=82). La cicatrisation postopératoire a été retardée pour trois jambes (2.9%) avec de très importants troubles trophiques. Deux patients se sont plaints de dysesthésies dans le territoire du nerf saphène externe. On a également observé des hématomes souscutanés étendus au niveau de six jambes (5.8%) et une dysesthésie postopératoire dans le territoire du nerf saphène interne au niveau de dix jambes (9.7%). A l'examen de contrôle, (suivi moyen=27 mois), l'examen clinique et l'investigation par Doppler/échogaphie a démontré des néoveines perforantes et incompétentes dans deux cas seulement. Les phlébographies ont montré une veine de Dodd incompétente dans une seule jambe, ce qui a été le point de départ de varices récidivantes importantes. Après une période de suivi moyen de plus de deux ans, on a observé de nouvelles varices dans 9 jambes. Avec cette technique, le taux de guérisons enregistrés était supérieur par aux autres techniques pratiquées auparavant. L'état veineux était inchangé dans seulement 10% des patients. Il n'y a jamais eu de cas d'aggravation.

     

The phlebotome in the management of incompetent perforating veins and venous ulceration

A shearing operation using a phlebotome has been used on 26 limbs of 24 patients with venous ulceration to deal with incompetent perforating veins. Only one ulcer has failed to heal or remain healed at mean operative follow-up of 24 months. Numbness, usually transient, and haematoma formation have been the only recorded complications. This procedure is recommended in the management of incompetent perforating veins associated with venous ulceration.     

Residual varicose veins below the knee after varicose vein surgery are not related to incompetent perforating veins

OBJECTIVE: The objectives of this study were to investigate the occurrence of residual varicose veins (visible and ultrasonic) at the below-knee level after short-stripping the great saphenous vein (GSV) and to investigate the possible role of preoperative incompetent perforating veins (IPVs) on the persistence of these varicose veins. METHODS: In this prospective study in 59 consecutive patients (74 limbs) with untreated primary varicose veins, a preoperative clinical examination and preoperative color flow duplex imaging were performed. Re-evaluation (clinical examination and color flow duplex imaging) was performed 6 months after surgery. Dissection of the saphenofemoral junction and short-stripping of the GSV from the groin to just below the knee level was performed without additional stab avulsions on the lower leg. The association between postoperative reflux in the three GSV branches below the knee level and preoperative IPV and the association between postoperative visible varicose veins in the GSV below knee level and preoperative IPV were determined with odds ratios with the help of a univariate and multivariate logistic regression analysis. RESULTS: Preoperative varicosities in the GSV below the knee were visible in 62 limbs (70%) and were visible after surgery in 12 limbs (16%). The number of limbs with reflux in the 3 below-knee GSV branches was as follows: anterior branch, 34 (49%) before surgery and 31 (44%) after surgery; main stem, 59 (79%) before surgery and 62 (91%) after surgery; and posterior branch, 49 (67%) before surgery and 46 (63%) after surgery. No statistically significant association between postoperative reflux in the three GSV branches and preoperative IPV nor between postoperative visible varicose veins and preoperative IPV was found. CONCLUSIONS: This study shows that reflux in the GSV below knee level after the short-stripping procedure persists in all below-knee GSV branches. Approximately 20% of patients with visible varicose veins in the GSV area below the knee level will have visible varicose veins in this area 6 months after the short-strip procedure. These clinical and ultrasonic residual varicose veins are not significantly related to the presence of preoperative IPV.     

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.