Real-time color duplex scanning after sclerotherapy of the greater saphenous vein

A color real-time duplex scanner was used to scan the greater saphenous vein in 89 limbs of 55 patients to study the efficacy of prior greater saphenous vein sclerotherapy. The greater saphenous vein was insonated from the saphenofemoral junction to the knee to evaluate both reflux to a standardized 30 mm Hg Valsalva maneuver and evidence of greater saphenous vein obliteration by sclerotherapy. These data were correlated with the number of sclerosing injections used (mean, 1.8; range, 1 to 6), time from the last injection (mean, 27.5 mo.; range, 3 to 55 mo), and concentration of injectant used (0.5% to 3% sodium tetradecyl sulfate). Fifty-one of 89 injected limbs (57%) demonstrated reflux through the saphenofemoral junction, and reflux down the more distal greater saphenous vein was found in 67 of 89 injected limbs (75%). Greater saphenous vein obliteration was noted in only 18 of 89 injected limbs (20%); two were totally obliterated, and 16 were partially obliterated. The greater saphenous vein was obliterated in 6% below a refluxing saphenofemoral junction and in 40% below a nonrefluxing junction. A greater saphenous vein obliteration rate of 9% was found with a refluxing greater saphenous vein, and 50% in a nonrefluxing greater saphenous vein. Femoral vein reflux was identified in 11 of the 110 limbs (10%) and in every case was associated with both saphenofemoral junction and greater saphenous vein reflux. We noted a trend toward more successful results with more concentrated injectate (3% sodium tetradecyl sulfate). Fifty percent of patients reported improvement in symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)     

Varicose vein surgery with preservation of the saphenous vein: A comparison between high ligation-avulsion versus saphenofemoral banding valvuloplasty-avulsion

Purpose: Surgical treatment of varicose veins with preservation of the greater saphenous vein (GSV) was studied.Methods: Patients with reflux at the saphenofemoral junction and grossly normal GSV were treated with two different surgical techniques: perivalvular banding valvuloplasty (PVBV-A) of the saphenous valve, wherein the diameter of the uppermost saphenous valve was narrowed by Dacron-reinforced silicone band (12 patients, 15 extremities); and high ligation (HL-A) of the saphenous vein, wherein the GSV was ligated flush with the femoral vein (14 patients, 16 extremities). Both groups also had varicose tributaries of GSV avulsed through multiple stab incisions.Results: In the HL-A group two GSV (13%) remained completely patent, 10 GSV (62.5%) thrombosed partially, and the remaining four GSV (25%) had complete thrombosis. In the PVBV-A group 12 GSV (80%) remained completely patent and without reflux, one GSV (7%) remained patent but showing reflux. Two GSV (13%) thrombosed completely. There were no surgical complications or recurrences (mean follow-up was 9.4 months for PVBV-A and 9.5 months for HL-A), and the postoperative recovery time was similar for both groups.Conclusions: Both techniques are equally effective in the early elimination of varicosities. Preservation of the saphenous vein is significantly better after PVBV-A (p < 0.01). A prospective randomized trial with long-term follow-up is required. (J VASC SURG 1994;20:684-7.)     

Anatomical Patterns of the Above Knee Great Saphenous Vein and its Tributaries: Implications for Endovenous Treatment Strategy

Objective: The aim of the present study was to analyse the anatomical patterns of the above knee great saphenous vein (GSV) and its tributaries in limbs with varicose veins in view of potential suitability for endovenous treatment. Methods: Limbs of a consecutive series of new patients with varicose veins presenting at the phlebologic clinic during a 4 month period were studied. In 73 limbs of 56 patients with varicose veins and both saphenofemoral junction and GSV reflux, anatomical patterns of the above knee GSV were defined as :

-‘complete’ GSV: main trunk visualised within the saphenous compartment from the groin to the knee

-‘incomplete’ GSV: main trunk partially visualised from the groin to mid thigh with a non-refluxing mostly hypoplastic distal GSV and a superficial tributary vein (STV) parallel to the GSV.

Results: 51 limbs (70 %) had a ‘complete’ GSV. In 4 of these 51 limbs reflux passed from the main GSV trunk to a STV at mid thigh level leaving a non-refluxing part of the GSV from mid thigh to the knee.

Conclusion: In only 64% of limbs with varicose veins the entire above knee GSV was involved in the disease. This may have implications for endovenous treatment strategy.     

Fate and clinical significance of saphenofemoral junction tributaries following endovenous laser ablation of great saphenous vein

BACKGROUND: Unlike surgery, endovenous laser ablation (EVLA) abolishes great saphenous vein (GSV) reflux but does not specifically interrupt the GSV tributaries at the groin. The fate and clinical significance of these tributaries were assessed in a prospective study. METHODS: Eight-one legs (70 patients) underwent colour flow duplex ultrasonography 12 months after GSV ablation for primary varicose veins. Saphenofemoral junction (SFJ) reflux, tributary patency, and recurrent or residual varicosities were recorded, and Aberdeen Varicose Vein Severity Scores (AVVSS) were compared with pretreatment values. RESULTS: The GSV had recanalized without evidence of reflux in two patients. None of the 81 legs showed SFJ reflux although one or more patent tributaries were visible in 48 (59 per cent); all were competent. In 32 legs (40 per cent) there was flush GSV occlusion with the SFJ and no tributaries were detectable. One leg showed evidence of neovascularization in the groin. AVVSS values were similar in groups with or without visible tributaries, both before and after EVLA: median (interquartile range) 13.9 (7.6-19.2) before EVLA and 2.9 (0.6-4.8) at follow-up in patients with visible tributaries, and 14.9 (9.2-20.2) and 3.1 (0.8-5.1) respectively in those without. Recurrent varicosities were present in one leg only, due to an incompetent mid-thigh perforating vein. CONCLUSION: Persistent non-refluxing GSV tributaries at the SFJ did not appear to have an adverse impact on clinical outcome 1 year after successful EVLA of the GSV.     

Neovascularization: an "innocent bystander" in recurrent varicose veins

OBJECTIVE: Varicose vein recurrence after surgery occurs in up to 60% of patients. A variety of technical factors have been implicated, but biological factors such as neovascularization have more recently been proposed. The objective of this study was to characterize the relative contribution of technical and biological factors to recurrence in a large prospective series of recurrent varicose veins. METHODS: Duplex and operative findings were recorded prospectively in a consecutive series of 500 limbs undergoing surgery for recurrent varicose veins between 1995 and 2005 in a university teaching hospital. Only limbs with previous saphenofemoral junction surgery were included. All limbs had preoperative duplex mapping by an accredited vascular technician who assessed the status of the great saphenous vein (GSV) in the thigh and groin, sought sonographic evidence of neovascularization, and reported on the presence of reflux in the short saphenous vein and perforator sites (typical and atypical). All operations were performed with an attending vascular surgeon as the lead operator. RESULTS: Primary GSV surgery was incomplete in 83.2% of limbs. A completely intact GSV system was present in 17.4% of limbs. An incompetent thigh saphenous vein was present in 44.2% of limbs, 37.6% had GSV stump incompetence with one or more intact tributaries, and 16% had both a residual thigh GSV and an incompetent stump with intact tributaries. Non-GSV sites of reflux were identified in 25% of limbs. Neovascularization was identified on duplex scanning in 41 (8.2%) limbs. However, in 27 of these, surgical exploration revealed a residual GSV stump with 1 or more significant tributaries. Each of the remaining 14 (2.8%) limbs had a residual incompetent thigh GSV. CONCLUSIONS: Despite reports to the contrary, neovascularization occurs in a relatively small proportion of patients with recurrent varicose veins. All recurrent varicose veins associated with duplex-diagnosed neovascularization are also associated with persistent reflux in the GSV stump tributaries, thigh GSV, or both. Recurrence after primary varicose vein surgery is associated with inadequate primary surgery or progression of disease, and neovascularization alone is not a cause of recurrent varicose veins.     

Clinical and hemodynamic significance of the greater saphenous vein diameter in chronic venous insufficiency

HYPOTHESIS: As the compliant greater saphenous vein (GSV) adjusts its luminal size to the level of transmural pressure, measurement of its diameter, reflecting the severity of hemodynamic compromise in limbs with GSV reflux, may simplify the hemodynamic criteria of patient selection for saphenectomy. OBJECTIVE: To evaluate the clinical significance of GSV diameter determined in the thigh and calf as a marker of global hemodynamic impairment and clinical severity in a model comprising patients with saphenofemoral junction and truncal GSV incompetence. DESIGN: A cohort study. SETTING: University-associated tertiary care hospitals in Brazil and England. PATIENTS: Eighty-five consecutive patients, aged 28 to 82 (mean, 46.2) years; 112 lower limbs with saphenofemoral junction and truncal GSV incompetence were investigated. INTERVENTIONS: Clinical examination was followed by clinical, etiological, anatomical, and pathophysiological classification (CEAP), vein duplex, and air plethysmography. The GSV diameter was measured on standing at the knee, and at 10, 20, and 30 cm above and below the knee, and in the thigh and calf, respectively, using B-mode imaging. The venous filling index (VFI), venous volume (VV), and residual volume fraction (RVF) were measured by air plethysmography. MAIN OUTCOME MEASURES: The GSV diameter was correlated with the VFI, VV, RVF, and CEAP. The value of the GSV diameter for predicting the presence of critical reflux (VFI >7 mL/s) or the absence of abnormal reflux (VFI <2 mL/s) was determined with receiver-operator curves. RESULTS: The GSV diameter increased significantly overall with CEAP (P<.001) and also increased progressively with proximity to the saphenofemoral junction. The VFI, VV, and RVF increased significantly from CEAP(0) through CEAP(4-6); the VFI correlated well with VV, RVF, and CEAP (P<.001 for all). The GSV diameter at all 7 limb levels studied correlated well with VV (except at the distal calf), VFI, RVF, and CEAP (P< or =.009 for all). A GSV diameter of 5.5 mm or less predicted the absence of abnormal reflux, with a sensitivity of 78%, a specificity of 87%, positive and negative predictive values of 78%, and an accuracy of 82%. A GSV diameter of 7.3 mm or greater predicted critical reflux (VFI >7 mL/s), with an 80% sensitivity, an 85% specificity, and an 84% accuracy. CONCLUSION: The GSV diameter proved to be a relatively accurate measure of hemodynamic impairment and clinical severity in a model of saphenofemoral junction and GSV incompetence, predicting not only the absence of abnormal reflux, but also the presence of critical venous incompetence, assisting in clinical decision making before considering greater saphenectomy.     

Late recurrent saphenofemoral junction reflux after ligation and stripping of the greater saphenous vein

OBJECTIVE: This study was done to determine the long-term incidence of refluxing epifascial-to-deep vein reconnections in the area of the former saphenofemoral junction after ligation of the true junction, along with all proximal tributaries, and resection of the greater saphenous vein. PATIENTS AND METHODS: A total of 125 limbs in 77 patients, representing 66% of 117 survivors among 602 patients who underwent operation between 1960 and 1967, were evaluated clinically and with duplex sonography for possible superficial-to-deep vein reconnections and clinical recurrence of thigh varicosities at a mean follow-up of 34 years. RESULTS: Clinical examination suggested saphenofemoral recurrence in 59 limbs (47%). In 11 instances these were actually varices associated with isolated superficial system reflux or reflux originating from a distally located perforating vein. Color-coded duplex ultrasonography demonstrated saphenofemoral reflux in 75 limbs (60%), versus the 48 identified on clinical examination (P <.001), and documented that the junction ligation had not been performed incorrectly by absence of the terminal valve or any patent proximal saphenous remnant. The reflux originated at the site of the ligated saphenofemoral junction in 53 limbs (71%) and from a nearby circumjunctional deep vein in the other 22 (29%). Of the real junctional recurrences, 22 appeared as a tangled cluster, and 31 involved a single-lumen varix. Only 27 recurrences were sufficiently symptomatic to warrant consideration of additional treatment; 25 of these were clinically evident, single-lumen, true junctional recurrences. CONCLUSIONS: This 34-year clinical follow-up study shows a 60% incidence of junctional and circumjunctional reconnections after ligation of the true saphenofemoral junction and its related tributaries. Color-coded duplex sonography is a necessary concomitant to clinical examination, detecting more recurrences and defining the pathologic anatomy to direct clinically indicated additional treatments.     

Patterns of Saphenous Venous Reflux in Women Presenting with Lower Extremity Telangiectasias

BACKGROUND: Telangiectasias have been treated with sclerotherapy without concomitant assessment or treatment of saphenous veins. OBJECTIVE: To clarify if ultrasound (US) mapping of saphenous veins is justifiable, this investigation determined prevalence of specific patterns of saphenous vein reflux in women with telangiectasias. METHODS: US mapping of the great and small saphenous veins (GSV, SSV) was performed in 1,740 extremities of 910 consecutive patients, mostly women (86%). A subgroup of 269 limbs of women with telangiectasias (CEAP C1 class) was included in this study. Patterns of GSV and SSV reflux were classified as perijunctional, proximal, distal, segmental, multisegmental, and diffuse. RESULTS: Reflux was detected in 125 extremities (46%): 5% had reflux in both the GSV and the SSV, 39% had GSV reflux, and 2% had SSV reflux. The most common pattern of GSV reflux was segmental (73%, 87/119). Prevalence of reflux was significantly greater in GSV versus SSV (p < .001). GSV segmental plus distal reflux (40%, 108/269) was significantly more prevalent than saphenofemoral junction or near junction reflux (4%, 11/269; p < .001). CONCLUSIONS: US mapping of the GSV in women with telangiectasias is justifiable, even in asymptomatic extremities. Further research will determine if segmental reflux should be treated to avoid evolution to severe valvular insufficiency.     

Endovenous Laser Ablation (EVLA) of the Anterior Accessory Great Saphenous Vein (AAGSV): Abolition of Sapheno-Femoral Reflux with Preservation of the Great Saphenous Vein

AimDuring surgery for sapheno-femoral junction (SFJ) and anterior accessory great saphenous vein (AAGSV) reflux, many surgeons also strip the great saphenous vein (GSV). This study assesses the short-term efficacy (abolition of reflux on Duplex ultrasound) of endovenous laser ablation (EVLA) of the AAGSV with preservation of a competent GSV in the treatment of varicose veins occurring due to isolated AAGSV incompetence.MethodThirty-three patients (21 women and 12 men) undergoing AAGSV EVLA alone (group A) and 33 age/sex-matched controls undergoing GSV EVLA (Group B) were studied. Comparisons included ultrasound assessment of SFJ competence, successful axial vein ablation, Aberdeen Varicose Vein Symptom Severity Scores (AVVSS) and a visual analogue patient-satisfaction scale.ResultsAt the 1-year follow-up, EVLA had successfully abolished the target vein reflux (AAGSV: median length 19 cm (inter-quartile range, IQR: 14–24 cm) vs. GSV: 32 cm (IQR 24–42 cm)) and had restored SFJ competence in all patients. Twenty of the 33 patients (61%) in group A and 14 of the 33 (42%) in group B (p = 0.218) required post-ablation sclerotherapy at 6 weeks post-procedure for residual varicosities. The AVVSS at 12 months follow-up had improved from the pre-treatment scores in both the groups (group A: median score 4.1 (IQR 2.1–5.2) vs. 11.6 (IQR: 6.9–15.1) p < 0.001; group B: median score 3.3 (IQR 1.1–4.5) vs. 14.5 (IQR 7.6–20.2), p < 0.001), with no significant difference between the groups. Patient-satisfaction scores were similar (group A: 84% and group B: 90%).Previous intervention in group A included GSV EVLA (n = 3) or stripping (n = 9). Thus, the GSV was preserved in 21 patients. The AVVSS also improved in this subgroup (4.4 (2.0–5.4) vs. 11.4 (6.0–14.1), p < 0.001) and SFJ/GSV competence was found to be restored at the 1-year follow-up.ConclusionsAAGSV EVLA abolishes SFJ reflux, improves symptom scores and is, therefore, suitable for treating varicose veins associated with AAGSV reflux.     

Segmental hypoplasia of the great saphenous vein and varicose disease.

OBJECTIVES: Primitive narrowing of great saphenous vein segments (saphenous hypoplasia) has been described in healthy limbs. The aim of the present study was to detect great saphenous vein segmental hypoplasia in limbs with varicose veins and to evaluate the local anatomical and haemodynamic patterns. MATERIALS AND METHODS: The incidence of saphenous hypoplasia and the local haemodynamic rearrangement were evaluated by duplex ultrasonography in 676 normal limbs and in 320 limbs with varicose veins. RESULTS: Segmental hypoplasia was demonstrated in 84 normal limbs and in 79 limbs with saphenous reflux. In the latter, the retrograde flow leaves the GSV at the proximal end of the hypoplastic segment to feed tributary veins. CONCLUSIONS: Saphenous hypoplasia occurs in varicose limbs more frequently than in healthy ones (p= >0.001). It greatly influences the path of the reflux and the anatomy of the varicose veins. GSV segmental hypoplasia can be detected preoperatively by duplex ultrasonography. Its occurrence may influence surgical management for two main reasons: in about 68% of varicose limbs with segmental hypoplasia, the distal GSV is competent. If the distal GSV is varicose, its size and flow direction is normalised by treating the accessory vein that bypasses the hypoplastic segment.     

Sapheno-femoral Junction Reflux in Patients with a Normal Saphenous Trunk

OBJECTIVE: To determine the patterns and clinical importance of saphenofemoral junction (SFJ) reflux in patients with chronic venous disease (CVD) and a normal great saphenous vein (GSV) trunk. METHODS: Fifteen hundred consecutive patients were examined using duplex ultrasound (DU) in three centres. Patients with reflux involving the SFJ and/or its tributaries only were included and its prevalence and patterns were studied. Patients with GSV trunk reflux or in any other veins were excluded. The SFJ diameter was categorised as normal, dilated or varicose. The results of surgery were evaluated by DU in 42 patients 1 year after the procedure. RESULTS: SFJ area incompetence with a competent GSV trunk occurred in 8.8% of limbs. It was significantly more common in CEAP class 2, 13.6% compared to class 3, 8.2% (p=0.03), class 1, 2.7%, class 4, 4.4% and classes 5 and 6 together, 1.5% (p<0.001 for all). The SFJ had a normal diameter in 21%, dilated in 62% and varicose in 17%. Reflux was seen in 39% of limbs with a normal SFJ diameter, in 85% of those with a dilated SFJ and in all varicose SFJs. Of the 42 operated limbs, 27 had ligation and division of the SFJ and tributary phlebectomies. Fifteen had tributary phlebectomies only, leaving the SFJ intact. At one-year follow-up, SFJ area reflux was found in six limbs (14.3%), involving the SFJ alone in 1, a main tributary in 1 and 4 small tributaries. No reflux was found in the GSV trunk. All but two of the 42 patients were satisfied with the results. CONCLUSIONS: SFJ reflux with tributary involvement and sparing of the GSV trunk occurs in 8.8% of CVD patients. Such reflux is found in the entire spectrum of CVD, but it is more common in class 2. Local surgery with or without SFJ ligation has very good results at 1 year. DU scanning prior to treatment is important in all patients so that the intact GSV can be spared.     

Recurrence rates following external valvular stenting of the saphenofemoral junction: a comparison with simultaneous contralateral stripping of the great saphenous vein.

OBJECTIVES: The incidence of recurrent varicose veins remains high despite the development of new ablative treatments for varicose veins associated with incompetence of the saphenofemoral junction. External valvular stenting (EVS) of the terminal and/or subterminal valves of the great saphenous vein (GSV) provides a reparative, physiological approach that requires long-term evaluation. The aim of this study was to compare recurrences following EVS with perforate invaginate (PIN) stripping of the GSV. METHODS: Included in the study were 193 patients (386 limbs) all of whom underwent simultaneous PIN-stripping of the GSV in one limb and EVS in the contralateral limb. Duplex scanning of the GSV and venous valves established suitability for each procedure. Only valves with visible, mobile cusps on ultrasound imaging are suitable for EVS. Stents were specifically designed Dacron reinforced silicone for left and right saphenofemoral junctions and for the subterminal valve. In a separate group of patients identified from a database where unilateral and bilateral stents had been implanted, 39 limbs with recurrent varices were examined clinically and ultrasonically to determine the aetiology of recurrences. RESULTS: Follow up was available to a maximum of 147 months. The total recurrence rate was 12.4%; stripping (22.2%) and EVS (4.6%) (P<0.01). The residual reflux as measured by postoperative Valsalva on duplex was 9% but rarely was associated with recurrences. The most common cause of recurrence was incompetent perforators and ovarian vein incompetence filling varices of the pudendal veins. CONCLUSION: This non-randomised study included more severely affected limbs in the PIN stripping limbs, favouring a better outcome in the EVS group. In those patients at an early stage of the disease process where venous valve structure is essentially intact, EVS is a physiological alternative to PIN stripping in the treatment of varicose veins.     

Prevalence of varicose veins and venous anatomy in patients without truncal saphenous reflux.

OBJECTIVES: To determine the prevalence and distribution of primary venous reflux in the lower limbs in patients without truncal saphenous reflux. DESIGN: Prospective cohort study. PATIENTS AND METHODS: One thousand and seven hundred and twelve patients with suspected venous disease were examined by duplex ultrasonography. Seven hundred and thirty-five patients had primary varicose veins with competent saphenous trunks. Limbs with truncal saphenous reflux, deep vein reflux or obstruction, previous injection sclerotherapy or vein surgery, arterial disease and inflammation of non-venous origin were excluded from further consideration. The CEAP classification system was used for clinical staging. Systematic duplex ultrasound examination was undertaken to assess the distribution of incompetent saphenous tributaries. RESULTS: The prevalence of primary reflux with competent saphenous trunks was 43%. Reflux of GSV calf tributaries was the most common. The majority of the limbs (96%) belonged to chronic venous disease classes C1 and C2 of the CEAP classification. CONCLUSIONS: Superficial venous reflux causing varicose veins in the presence competent saphenous trunks is very prevalent in this series in contrast to other studies, presumably reflecting differing patient populations. Our data clearly show that varicose veins may occur in any vein and do not depend on truncal saphenous incompetence. Careful duplex ultrasound evaluation allows the pattern of venous reflux to be established in this group of patient ensuring appropriate management of varices.     

Patterns of saphenous reflux in women with primary varicose veins

OBJECTIVE: Varicose veins have been linked to great saphenous vein (GSV) reflux and in particular, with reflux at the saphenofemoral junction (SFJ). Early stages of disease, however, may be associated with limited, localized reflux in segments of the GSV and/or small saphenous vein (SSV). Ultrasound mapping of saphenous veins was performed to determine patterns of GSV and SSV reflux in women with simple, primary varicose veins. METHODS: Ultrasound mapping was performed prospectively in 590 extremities of 326 women with varicose veins (CEAP C 2 class) but without edema, skin changes, or ulcers (C 3 to C 6 ). Average age was 42 +/- 13 (SD) years (range, 8 to 87). Patterns of GSV and SSV reflux, obtained in the upright position, were classified as I: perijunctional, originating from the SFJ or saphenopopliteal junction (SPJ) tributaries into the GSV or SSV; II: proximal, from the SFJ or SPJ to a tributary or perforating vein above the level of the malleoli; III: distal, from a tributary or perforating vein to the paramalleolar GSV or SSV; IV: segmental, from a tributary or perforating vein to another tributary or perforating vein above the malleoli; V; multisegmental, if two or more distinct refluxing segments were detected; and VI: diffused, involving the entire GSV or SSV from the SFJ or SPJ to the malleoli. RESULTS: Reflux was detected in 472 extremities (80%): 100 (17%) had reflux in both the GSV and SSV, 353 (60%) had GSV reflux only, and 19 (3%) had SSV reflux only, for a total prevalence of 77% at the GSV and 20% at the SSV. The most common pattern of GSV reflux was segmental (types IV and V) in 342 (58%) of 590; either one segment in 213 (36%) or more than one segment with competent SFJ in 99 (17%), or incompetent SFJ in 30 (5%), followed by distal GSV reflux (type III) in 65 (11%), proximal GSV reflux (type II) in 32 (5%), diffused throughout the entire GSV (type VI) in 10 (2%), and perijunctional (type I) in 4 (<1%). GSV refluxing segments were noted in the SFJ in 72 (12%) and in the thigh in 220 (37%), and leg (or both) in 345 (58%). CONCLUSIONS: The high prevalence of reflux justifies ultrasound mapping of the saphenous veins in women with primary varicose veins. Correction of SFJ reflux, however, may be needed in 相似文献   

Clinical significance of ostial great saphenous vein reflux.

PURPOSE: To evaluate anatomical and haemodynamic differences in patients with great saphenous vein (GSV) insufficiency by duplex scanning and air plethysmography. MATERIAL AND METHODS: Duplex scanning and air plethysmography examination were undertaken. One hundred and twenty-one limbs in 91 patients were selected prospectively and divided into three groups: group A consisted of 27 controls; group B consisted of 25 limbs with GSV reflux and normal saphenous femoral junction (SFJ) and group C consisted of 69 limbs of patients with GSV and SFJ reflux. The presence of reflux and GSV diameter (SFJ, proximal and medial thirds of the thigh, the knee and medial and distal thirds of the calf) were assessed by duplex scanning. Air plethysmography was used to evaluate haemodynamic parameters: total venous volume (VV), venous filling index (VFI), residual volume fraction (RVF) and ejection fraction (EF). RESULTS: There was a significant difference in GSV diameter among the three groups in almost all segments evaluated (e.g. medial thigh group A = 2.4 SD 0.3 mm; B = 3.2 SD 0.7 mm; C = 5.9 SD 2.2mm p<0.001, Anova). A significant difference in VFI was found among the groups (group A = 1.2 SD 0.5; B = 2.0 SD 1.4; C = 4.0 SD 2.5 p<0.05, Anova). VV was statistical different between groups A and C (p = 0.004) and B and C(p = 0.03). EF and RVF were comparable in all groups. The VFI was normal in 68% in group B comparing with only 14.5% in group C patients, finding a reflux more than 5ml/s (determined by VFI) in 26.1% of the group C patients, comparing with only 4% of group B patients (p<0.05). CONCLUSION: We have shown that in patients with GSV reflux those with incompetence of the ostial valve of the GSV show greater venous reflux and dilatation of the saphenous trunk than those in whom the ostial valve is competent.     

Duplex ultrasound scan findings two years after great saphenous vein radiofrequency endovenous obliteration

OBJECTIVE: To assess the clinical and duplex ultrasound scan findings in the groin and thigh 2 years after great saphenous vein (GSV) radiofrequency endovenous obliteration (RFO). METHODS: Sixty-three limbs in 56 patients with symptomatic varicose veins and GSV incompetence were treated with RFO, usually with adjunctive stab-avulsion phlebectomies, and examined at a median follow-up of 25 months, by using a color-coded, duplex sonography protocol that mandated views in at least two planes of the saphenofemoral junction (SFJ) and its tributaries and at three GSV levels in the thigh. RESULTS: The commonest duplex finding in the groin was an open, competent, SFJ with a < or =5-cm patent terminal GSV segment conducting prograde tributary flow through the SFJ (82%). Despite the presence of a total of 104 patent junctional tributaries, SFJ reflux was uncommon, affecting only five limbs. GSV truncal occlusion was observed in 90% of treated GSVs. Limited segmental treatment was successful in three limbs with a midthigh reflux source well below competent terminal and subterminal valves. Six GSV trunks had partial or no occlusion, but only one refluxed. These were anatomical RFO failures (9.5%) but were clinically improved, including the refluxing limb. Neovascularity was not identified in any groin. Thigh varicosities were observed in 12 limbs, including telangiectasias and isolated small tributary branches. New varicosities, linked to refluxing thigh perforators (two), or patent SFJ tributaries (three), were present in five limbs. CONCLUSION: RFO is the ideological opposite of high ligation without GSV stripping. It leaves physiologic tributary flow relatively undisturbed, does not incite groin neovascularity, eliminates the GSV as a refluxing conduit in >90% of limbs and has a 2-year, postadjunctive phlebectomy varicosity prevalence of 7.9%, with symptom score improvement in 95% of limbs with an initial score higher than zero.     

Natural history of the great saphenous vein stump following endovenous laser therapy

Background: Little is known about the ideal residual length of the great saphenous vein (GSV) stump and its potential role in complications such as acute deep venous thrombosis (DVT) and recanalization. This study was designed to learn about the natural history of the residual GSV stump length following endovenous laser treatment. Methods: Prospective data were collected from 50 limbs of 50 patients over an 11-month period. Clinical assessment and duplex ultrasound were performed preoperatively, at 24 hours and at 3 months after the procedure. Results: The residual GSV stump decreased in length from a mean of 15 mm at 24 hours to 13 mm at 3 months after the procedure. None of the patients developed acute DVT or proximal recanalization when the laser tip was positioned 28 mm distal to the saphenofemoral junction. Conclusion: Endovenous laser therapy of the GSV for symptomatic reflux is safe and effective. The residual GSV stump decreased in length over a 3-month period.     

Validation of a new duplex derived haemodynamic effectiveness score, the saphenous treatment score, in quantifying varicose vein treatments

ObjectivesTo evaluate a duplex-derived score for varicose vein treatments using numerical values of haemodynamic effectiveness.DesignThe saphenous treatment score (STS) was developed prospectively to compare the effect of endovenous treatments on reflux within saphenous segments.PatientsSixty-six patients were randomised to endovenous laser ablation (EVLA) or ultrasound-guided foam sclerotherapy (UGFS) to the great saphenous vein (GSV).MethodsAssessments included the Aberdeen varicose vein severity score (AVVSS), the venous clinical severity score (VCSS), the venous filling index (VFI) and the STS.ResultsA mean STS of 5.70 decreased to 3.30, P < .0005, post-treatment. The median (IQR) AVVSS, VCSS and VFI (ml/sec) decreased from 21.52(15.48) to 18.86(11.27), P = .14, from 6(4) to 3(4), P < .0005 and from 7.1(6.9) to 1.9(.9) P < .0005, respectively. In 15 patients requiring additional UGFS the mean STS values decreased from 5.8 to 4.13 and then to 2.6 P < .0005, respectively. The individual above and below knee mean treatment differences in STS on 38 EVLA and 28 UGFS patients were 1.92 and .87 (EVLA) compared to 1.57and .29 (UGFS) P = .001, respectively.ConclusionsThe STS has been shown to grade the haemodynamic effects of different treatments as well as ongoing treatments on the GSV.     

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.     

Comparative Study of Outcome of Duplex Ultrasound-Guided,Catheter-Directed Foam Sclerotherapy and Radio-frequency Ablation in the Management of Great Saphenous Varicose Veins

Chronic venous insufficiency of lower limbs is a common problem in adults. We compared the two modalities, namely duplex ultrasound-guided, catheter-directed foam sclerotherapy (UGFS) and radio-frequency ablation (RFA), in the management of great saphenous varicose veins using clinical assessment (Venous Clinical Severity Score, Venous Disability Score) and duplex imaging. Patients presenting with great saphenous vein (GSV) varicosity due to incompetent saphenofemoral junction (SFJ) were selected and randomly assigned in each arm, i.e., duplex UGFS group and RFA group. Patients were assessed on days 7, 30, and 90 both clinically and sonologically. Clinical assessment was based on the Venous Clinical Severity Score (VCSS) and Venous Disability Score (VDS). Obliteration of the treated GSV segment was noted in all the limbs of the RFA group (31/31) on duplex sonography on days 7, 30, and 90, while in the UGFS group, out of 30 limbs, obliteration was successful in 28 (28/30) and 2 had treatment failure. However, outcome of both the groups were statistically comparable (P value?>?0.05). After the procedure, improvement in the VCSS was noted in both the study arms in every follow-up and both the modalities were found to be equally effective. Improvement in the Venous Disability Score was there on every follow-up, but maximum improvement was seen on the second visit, i.e., post-treatment day 30. Improvement was statistically significant and equal in both arms after the initial 1 week. Foam sclerotherapy, especially catheter-directed, is as effective as radio-frequency ablation in achieving anatomical obliteration and yielding relief in clinical signs and symptoms in patients with GSV varicosity with SFJ incompetence.