Air plethysmography: the answer in detecting past deep venous thrombosis

PURPOSE: In this study we assessed the accuracy of air plethysmography (APG) as a means of detecting earlier deep venous thrombosis (DVT), in comparison with venography, to develop a preoperative test for patients with varicose veins. METHODS: In this retrospective analysis of prospectively acquired data, 202 patients referred with the clinical suspicion of chronic venous obstruction (224 lower limbs) and 41 patients (41 lower limbs) who had symptoms and signs suggestive of DVT, but had deep veins that appeared normal on venography, were studied with both venography and APG. RESULTS: The results of venography were negative for past DVT in 169 legs and confirmed past DVT in 96 limbs. The DVTs were confined to the calf in 19 limbs and were found at popliteal level, more proximal, or both in 77 limbs. A total of 95% of the limbs that had earlier proximal DVT (73 of 77) were identified by means of an APG outflow fraction with occlusion of the superficial veins in the first second (OFs) of less than 28%. This is analogous to the Q wave of the electrocardiogram, which is a means of denoting the presence of myocardial infarction. The specificity rate of the method in the detection of past proximal DVT was 96%, the positive predictive value was 92%, and the negative predictive value was 98%. CONCLUSION: APG is a practical, inexpensive, easy-to-perform, accurate, noninvasive method for the diagnosis of hemodynamically significant (ie, proximal or extensive calf DVT) chronic venous obstruction that could replace venography.     

Non-saphenofemoral Venous Reflux in the Groinin Patients with Varicose Veins

OBJECTIVES: To investigate the incidence, clinical significance, anatomical variation and physiology of non-saphenofemoral venous reflux (non-SF reflux) in the groin. DESIGN: Prospective study. MATERIALS: A total of 1072 vascular diagnostic workups in 680 patients with possible venous diseases to the legs were included. METHODS: Duplex scanning and air plethysmography. RESULTS: A total of 1022 legs had venous diseases. Of these, 101 (9.9%) had non-SF reflux in the groin. Such reflux occurred in recurrent varicose veins (RVV) in 16.3%, in primary varicose veins (PVV) in 6.1% and in deep venous thrombosis (DVT) in 8.0%. Two patterns of reflux were distinguished: epigastric reflux from lower abdominal wall veins (71 legs) and pudendal reflux from perineal and/or gluteal veins (30 legs). Pudendal reflux was almost exclusive to women and did not occur with DVT. If there was only non-SF reflux at the groin the venous filling indices (VFI) were close to normal (1.7+/-1.0 ml/s for RVV, 1.9+/-1.2 for PVV, 1.7+/-1.0 for DVT) and no active ulcers were observed. However, if non-SF reflux was associated with saphenofemoral or other reflux the VFIs (3.3+/-2.3 ml/s for RVV, 3.8+/-1.5 ml/s for PVV) were abnormal (p <0.05) and ulcers occurred in 11/32. CONCLUSION: Non-SF reflux in the groin is common. Such reflux may be missed at initial surgery and lead to recurrence of varicose veins. However, the venous physiological disturbance of such reflux is mild and it is not associated with ulcers unless combined with reflux at other sites in the leg.     

Graduated compression stockings (20-30 mmHg) do not compress leg veins in the standing position

BACKGROUND: Since graduated compression stockings (GCS) reduce the risk of deep venous thrombosis (DVT) in both hospital and ambulant patients, we checked the compressive efficiency of 20-30 mmHg GCS in the standing position. METHODS: In 30 volunteers (17 normal legs, 13 varicose legs), duplex ultrasound was used to measure the internal diameters of the long saphenous vein, posterior tibial veins, peroneal veins, and soleal veins in the lying and standing position and with and without 20-30 mmHg GCS. RESULTS: Graduated compression stockings effectively compressed both superficial and deep veins in supine individuals but not the superficial or the deep veins when standing. In the varicose leg, the stockings did not compress the long saphenous vein at the mid-calf level even when supine. In the varicose leg the long saphenous vein was constricted at the upper band of the stocking, which might explain why superficial venous thrombosis is more common when compression stockings are worn. CONCLUSIONS: In the standing position, GCS did not compress the deep or superficial veins of the calf.     

Whole-leg duplex mapping for varicose veins: observations on patterns of reflux in recurrent and primary legs, with clinical correlation.

BACKGROUND: the variability of venous reflux patterns complicate the management of venous disease. Our study investigates specific variations in venous anatomy and patterns of reflux in varying clinical situations. METHODS: prospective analysis of 464 legs in 355 patients was performed by complete duplex venous mapping of both primary and recurrent varicose veins. Hand Held Doppler (HHD) and Duplex Ultrasonography (Duplex US) observations in the popliteal fossa were compared in a subgroup of 89 patients with primary varicose veins. Distribution of venous system disease was correlated with clinical severity in a subgroup of 117 affected legs which was representative of the overall study group. RESULTS: sapheno-femoral junction (SFJ) incompetence predominated in both primary and recurrent varicose veins. Only 21% of primary legs and 25% of recurrent legs had sapheno-popliteal junction (SPJ) incompetence. SPJ incompetence was present in only 42% of cases where reflux in the popliteal region on HHD had been demonstrated. A proportion of both primary and recurrent varicose veins had evidence of deep venous incompetence (DVI). Sixty-four percent of primary leg ulcer patients had superficial incompetence alone. In patients with recurrent varicosities and ulceration, 57% had SPJ incompetence, 64% multiple sites and 50% DVI. CONCLUSION: the complex variations of varicose vein anatomy and functional pathology in the lower limb are currently best assessed by complete whole-leg venous duplex mapping.     

Role of venous elasticity in the development of varicose veins

A reduction in the 'elasticity' of the venous system has been proposed as a precursor of venous insufficiency, but the concept remains controversial. This study was designed to develop a method of assessing venous elasticity, and to use this method to investigate the aetiology of varicose veins. Simultaneous measurements of calf volume (determined using strain gauge plethysmography) and venous pressure (obtained via a dorsal foot vein) were made during venous occlusion plethysmography. The elastic modulus, K, defined as stress/strain when the veins are full, was calculated from the pressure/volume relationship. The elastic modulus was determined in 19 normal legs, 33 legs with superficial venous insufficiency, 16 legs with deep venous insufficiency, and 18 legs of a high risk group of volunteers or patients without varicose veins but with a strong history of factors associated with their development. The results showed a clear difference in elasticity between normal limbs and limbs with varicose veins, and also between normal limbs and high risk limbs. These results support the hypothesis that reduced elasticity has a role in the development of varicose veins and precedes the onset of valvular incompetence.     

Incidence of deep vein thrombosis after varicose vein surgery

BACKGROUND: Varicose vein surgery is generally considered to have little risk of postoperative deep vein thrombosis (DVT). This prospective study examined the incidence of DVT in patients undergoing varicose vein surgery. METHODS: Lower leg veins were assessed before operation by duplex ultrasonography in 377 patients, and reassessed 2-4 weeks after surgery, and again at 6 and 12 months. Patients were instructed to contact a physician if symptoms consistent with DVT occurred before the scheduled follow-up appointment. Preoperative prophylaxis (a single dose of subcutaneous heparin) was left to the discretion of the vascular surgeon. RESULTS: DVT was detected in 20 (5.3 per cent) of the 377 patients. Of these, only eight were symptomatic and no patient developed symptoms consistent with pulmonary embolus. Eighteen of the 20 DVTs were confined to the calf veins. Subcutaneous heparin did not alter the outcome. No propagation of thrombus was observed and half of the DVTs had resolved without deep venous reflux at 1 year. CONCLUSION: The incidence of DVT following varicose vein surgery was higher than previously thought, but these DVTs had minimal short- or long-term clinical significance.     

Pulsating varicose veins!! The diagnosis lies in the heart

Right heart failure is associated with increased systemic venous pressure, which can be diagnosed clinically with the findings of elevated jugular venous pressure, pulsatile liver and distinctive cardiac murmurs (precordial systolic). Severe tricuspid regurgitation (TR) has occasionally been known to lead to marked pulsation of varicose veins. We report three cases that were referred to the vascular clinic of Royal Perth Hospital in which the patients involved had unilateral (right leg) varicose veins and chronic venous ulcers. On clinical examination all three patients had pulsations along the course of the varicose long saphenous vein up to the mid calf. The main differential diagnosis was arterio-venous malformation, which was excluded by compression of the sapheno-femoral junction and demonstrating absence of pulsation in the long saphenous vein. A venous duplex scan showed a grossly incompetent sapheno-femoral junction with abnormal wave forms. Two of the cases were managed conservatively with compression dressing. The option of sapheno-femoral junction ligation was reserved in one patient who had unsettling cellulitis and oedema of the lower limb in spite of compression dressing and optimal conservative management. All three patients had improvement in ulcer size at 3-month follow up with compression therapy. This article highlights that in cases of right heart failure the venous pressures can be felt as low as the mid calf level and that can be a cause of the venous ulcers. There should be a high suspicion of right heart failure in patients with late onset venous insufficiency.     

Results and significance of colour duplex assessment of the deep venous system in recurrent varicose veins.

OBJECTIVES: To establish the status of the deep veins in patients presenting with recurrent varicose veins and the effect on treatment decisions. DESIGN: Retrospective clinical series. MATERIALS AND METHODS: Duplex examination of 570 consecutive patients (843 limbs) presenting with recurrent varicose veins (CEAP C2-4). RESULTS: Approximately one third of these patients (34.8%:294 limbs) had no deep venous abnormality; 173 limbs with superficial vein abnormalities only had great and/or small saphenous junction incompetence, the remaining 121 legs had abnormal perforating or communicating veins. Deep venous abnormalities were found in 549 limbs with evidence of persisting deep venous obstruction in only 20. Deep venous incompetence was found in 529 limbs (62.7% of all legs). However three segment incompetence (common femoral, femoral and popliteal veins) was found in only 181 legs (21.4%), two segment incompetence in 137 (16.2%) and one segment incompetence in 211 (25%). CONCLUSIONS: Deep vein incompetence is common in patients with recurrent varicose veins. Deep venous obstruction is an infrequent finding but total deep venous reflux (three segment incompetence) affects just under one quarter of all limbs with recurrent varicose veins. Ablation or surgery of varicose veins in this group may be less effective. Patients should be advised of the implications of this finding.     

Lower limb varicosity in patients, with indication for total knee arthroplasty

Preoperative treatment of the peripheral venous pathology in patients with indication for total knee arthroplasty (TKA) would reduce the risk of postoperative deep venous thrombosis (DVT). Between 1997 and 2004, 110 patients were evaluated for TKA. 35 had also varicose veins in the lower limbs. 4 patients were excluded because of absolute contraindications for surgery. 31 patients presented varicose disease, in different stages according with CEAP. The patients were treated surgically (Babcock or Muller technique), phlebotomy drugs and mechanical contention. In a single case the TKA was done without any preoperative treatment of the varicosities. TKA was done after 8-12 weeks. DVT prophylactic measures were undertaken in all 95 cases. Results were good except 2 cases of DVT and 1 case or pulmonary embolism in patients with preoperative treatment of the venous disease. The patient with no preoperative treatment of its varicose veins developed DVT with chronic, persistent oedema. Preoperative treatment of the varicose veins in the lower limb is mandatory for a successful TKA.     

下肢静脉造影在下肢静脉曲张患者中的应用及阻塞性下肢静脉曲张发生的预测因素

目的 探讨下肢静脉造影检查在下肢静脉曲张中应用的临床意义,并分析阻塞性下肢静脉曲张可能相关的预测因素.方法 选取2019年1月至2021年12月因下肢静脉曲张于海军军医大学第二附属医院诊治的74例患者(111条患肢)为研究对象,对所有患肢行下肢静脉造影检查,采用病例报告表形式记录患者相关信息,根据有无深静脉阻塞表现分为...     

Definition of the post-thrombotic syndrome, differences between existing classifications.

BACKGROUND: Accepted diagnostic criteria exist for the diagnosis of deep vein thrombosis (DVT). However, no uniform definition for the diagnosis and treatment of the post-thrombotic syndrome (PTS) exists. We examined the various definitions of PTS that are used and their relationships with invasive venous pressure measurement. METHODS: Patients who had previously suffered a documented DVT underwent clinical evaluation of both lower limbs in which we used five clinical definitions to grade PTS. We included the definition of Widmer, the CEAP classification, the venous clinical severity score (also without compression therapy), and the definitions according to Prandoni and Brandjes in the evaluation. We compared all the clinical scoring systems with invasive ambulatory venous pressure measurement. RESULTS: In total 124 patients were enrolled in whom both legs were evaluated. Thirteen patients had previously suffered bilateral DVT and nine patients had had an ipsilateral recurrent DVT. In the limbs with DVT, 10 (7%) to 29 (21%) were defined as severe PTS, compared to 0-4 (4%) in the control legs. Mild-to-moderate PTS in the DVT legs ranged from 23 to 49%, compared to 13-34% in the control legs. Overall the presence of any PTS in the DVT legs varied from 30% (VCS without compression) to 66% (Brandjes). The scoring systems of Brandjes and VCS showed a tendency towards more legs to be defined as severe PTS. Absolute frequencies of PTS in DVT legs were highest for the classifications according to Widmer, Prandoni and Brandjes. Differences in proportions of any PTS calculated between DVT and control legs varied from 18 to 39%, while odds ratios varied between 2.2 and 5.2 for the different definitions. The CEAP classification and definition of Brandjes show a moderate relation to Widmer, kappa=0.53 and 0.52, respectively. The VCS shows in all comparisons a poor correlation (kappa 0.22-0.41). Prandoni has a moderate correlation with most definitions (kappa 0.40-0.44). CONCLUSION: All clinical definitions of PTS were highly associated with the reference standard of ambulatory venous pressure, with higher AVPs observed in the more severely affected groups. The ability of the scoring systems to discriminate between DVT and control legs as well as the observed prevalence of PTS differed substantially. In part this is due to the considerable overlap in AVP in the different clinical groups, reflecting the fact that our reference standard has substantial deficiencies. No clear advantage was found in any one system of classification over the rest.     

Venous wall function in the pathogenesis of varicose veins.

Three theories have been proposed to explain the cause of varicose veins, citing three different factors as the primary cause: valvular incompetence, a weakness of the vein wall, and increased arterial inflow associated with multiple arteriovenous communications. This study was designed to determine the cause of varicose veins with respect to these three factors. Duplex scanning techniques were used to assess the venous valves, and simultaneous measurements of calf volume (strain-gauge plethysmography) and venous pressure made during venous occlusion plethysmography were used to determine the elasticity of the venous wall and the rate of arterial inflow. Fifty-one control legs and 36 legs with superficial venous insufficiency were examined. Risk factors were used to divide the control legs into two groups: low risk or normal (23 legs) and high risk (28 legs). The results obtained in the high-risk limbs demonstrated a significantly reduced vein wall elasticity (p less than 0.001) and increased arterial inflow (p less than 0.005) compared with the normal limbs, with no corresponding increase in the incidence of valvular incompetence. These results clearly suggest that the role of the venous valves in the development of varicose veins is secondary to changes in the elastic properties of the vein wall and the rate of arterial inflow.     

Venous reflux and venous distensibility in varicose and healthy veins.

OBJECTIVES: The aim of this study was to analyse venous diameter changes and venous reflux parameters, assessed during a standardised Valsalva manoeuvre in healthy subjects and in patients with varicose veins. METHODS: Measurements were carried out in 444 vein segments, (96 legs of 48 healthy volunteers, 52 legs of 35 patients with varicose veins). The common femoral vein (CVF), the femoral vein (FV) and the great saphenous vein (GSV) were investigated. The parameters of reflux and the relative venous diameter change (VD diff %) were measured simultaneously during a standardised Valsalva manoeuvre. RESULTS: Venous diameter changes during Valsalva manoeuvre (VD diff) were significantly greater in the GSV and in the deep veins of varicose patients compared to healthy subjects. The median (Interquartile range) of VD max in the CFV was: 13.1 (3.5) mm and 11.2 (3.4) mm (p=0.0002, Mann-Whitney - U test), in the FV 7.8 (2.7) mm and 6.9 (2.0) mm (p=0.01, Mann-Whitney), in the GSV: 7.3 (3.7) mm and 4.2 (1.1) mm (p<0.0001, Mann-Whitney) for the varicose and healthy veins respectively. Good correlation was seen for the retrograde peak reflux velocity (PRV) and VD diff % in varicose veins (r=0.71 (0.57 - 0.81) p<0.0001, Mann-Whitney). CONCLUSION: Relative venous diameter--changes during a standardised Valsalva manoeuvre are significantly larger in the deep and superficial veins of varicose vein patients compared with healthy veins, the increased distensibility correlates with venous reflux parameters in varicose vein patients.     

THE USE OF ROUTINE DUPLEX SCANNING IN THE ASSESSMENT OF VARICOSE VEINS

Background : Clinical assessment has been shown to compare poorly with results of hand-held Doppler examination or venography in the evaluation of varicose veins. Although the use of duplex scanning has been well described in the assessment of varicose veins, there are few data comparing clinical and Doppler assessment with results of duplex scans. Methods : A total of 188 patients were referred with varicose veins to a sole specialist vascular surgeon over a 1-year period. After clinical and Doppler assessment, all patients were referred for a duplex scan which was performed by a trained vascular technician. The results of the duplex scan were compared retrospectively with the clinical and Doppler findings. Results : A total of 315 legs were assessed over this period, with 38.7% having recurrent disease and 31.4% having trophic skin changes or ulceration. On duplex scanning, 198 legs (62.9%) had saphenofemoral junction incompetence, 61 legs (19.4%) had saphenopopliteal junction incompetence, 94 legs (29.8%) had perforator incompetence and 24 legs (7.6%) had deep venous incompetence. The respective sensitivity of clinical and Doppler assessment at these sites was 71.2, 36.1, 43.6 and 29.2%. If patients who were felt to have sole saphenofemoral junction incompetence clinically were treated by high ligation, stripping to the knee and stab avulsions, 28.9% would have had sites of reflux untreated. Conclusions : Clinical and Doppler assessment is unreliable. Routine duplex scanning is likely to reduce recurrence by identifying sites of reflux with greater accuracy.     

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.     

Primary Lower Limb Varicosities Arising Directly from Normal Deep Venous Systems: A Series Report

Primary lower limb varicosities classically arise from incompetence of the junction of the superficial and the deep venous systems with retrograde flow into the saphenous veins. However, some patients with superficial varicosities have no demonstrable incompetence of the saphenofemoral or saphenopopliteal junctions. In this study, we examined 52 limbs with primary varicose disease in whom saphenofemoral and saphenopopliteal incompetence had been excluded (clinically and with the hand-held Doppler) using a duplex ultrasound scan. Seventeen (33%) of the limbs had superficial varicosities despite normal long and short saphenous veins. The varicosities in 12 of these legs originated from groin veins, while those in the remaining 5 limbs communicated directly with normal deep veins. In this latter group of limbs, the superficial varicosities were found on the lateral aspect of the thighs only. Primary varicosities arising from normal deep venous systems have not been previously described, and are relatively rare (1.0% of patients referred to our clinic). As this complex venular anatomy was only detected on duplex scanning, we conclude that this study provides further evidence of the need for this imaging modality in patients with varicose disease of uncertain origin and/or those with an unusual distribution of superficial varicosities.     

Reflux patterns in the ovarian and hypogastric veins in patients with varicose veins and signs of pelvic venous incompetence

Patients with varicose veins who also had clinical and/or duplex ultrasound findings suspicious of pelvic venous incompetence (PVI) underwent selective retrograde catheter phlebography of the pelvic veins. One hundred and one patients (all female, mean age 49.3 years) underwent selective phlebography of the pelvic veins. In 68 cases (67.3%) a varicose vein recurrence after previous stripping of the greater saphenous vein was present, and about half the patients (n=45, 44.6%) were multipara ( > or =2 episodes of childbirth). The presence and extent of any reflux was documented and the ovarian and pelvic veins affected by the reflux were recorded. Retrograde selective phlebography demonstrated a PVI in 75 patients (74.2%). The left ovarian vein and the right hypogastric vein were most frequently affected by reflux (n = 41, 54.6% each). The left hypogastric vein was incompetent in 35 patients (46.6%) and the right ovarian vein in 3 cases (4%). In about half the patients with pelvic venous incompetence, reflux was demonstrated in more than one of the main pelvic veins (n=38, 50.6%). Fifty-one (68%) of the 75 patients with pelvic venous incompetence had varicose vein recurrence after previous stripping of the greater saphenous vein. Extension of the reflux into varicose veins of the groin or lower leg was demonstrated in 44 patients (58.6%). Thirty-nine patients (52%) received treatment for their pelvic venous incompetence (coil embolisation, sclerotherapy or videoscopic ovarian vein ligation). Pelvic venous reflux was present in 75% of our study population. Combined reflux in more than one pelvic vein was common and in about 60% of cases the pelvic reflux was shown to feed varicose veins of the legs. Therefore, typical clinical and/or duplex findings should lead to a strong suspicion of pelvic venous incompetence and reduce the need for selective retrograde catheter phlebography in this selected group of patients.     

Effect of high-dose corticosteroids on the incidence of deep vein thrombosis after total hip replacement

Summary Fifty patients receiving uncemented total hip prostheses were examined by venography of the legs on the 2nd postoperative day. The patients were randomly divided into two groups, a non-steroid group (n = 26) and a steroid group (n = 24). Both groups received dextran thrombo-prophylaxis. The patients in the steroid group were treated with high-dose corticosteroids. The incidence of deep vein thrombosis (DVT) was 38% (19/50). No patients had clinical signs or symptoms of DVT. All thrombi were located distally in the leg. DVT was bilateral in nine patients, in the operated leg in three, and in the non-operated leg in seven. The administration of high-dose corticosteroids did not influence the incidence or pattern of DVT. All patients were followed up clinically and plethysmographically up to 12 months after surgery. Distally located asymptomatic DVT were not given specific treatment. The postoperative course was uneventful except for one patient in each group who developed clinically, apparent DVT more than 3 weeks after operation, although the initial venographic studies were normal.     

Endovascular laser ablation of the greater saphenous vein for varicose veins: our initial experience

Laser treatment of primary varicose veins of the legs is a new mini-invasive technique which represent an alternative to the safenectomy. Endovascular laser treatment is based on the employ of laser to destroying the vascular wall and inducing fibrosis. This technique is not without complications: burns, paraesthesias, haematomas, but most of all disappear in few days. Encouraged by the promising results reported in literature, we have performed 18 laser ablation of greater saphenous vein since 2003 till today. Our patients had a good post-operative course and a follow up without troubles (3-17 months). We think that laser treatment is effective in the treatment of the primary varicose veins of the legs. It requests attention and experience in dosing the laser energy for minimizing the complications. Today there isn't long term follow up in literature.