Prevalence of deep venous reflux in patients with primary superficial vein incompetence

PURPOSE: This prospective study was designed to determine the prevalence of deep reflux and the conditions under which it may occur in patients with primary superficial venous reflux and absence of deep venous thrombosis (DVT). METHODS: We studied 152 limbs in 120 consecutive patients in the standing position who had superficial venous reflux with color flow duplex scanning. Limbs with documented evidence of DVT or post-thrombotic vein wall changes during the examination were studied but not included in the analysis. Limbs were divided into those that had at least reflux in the saphenofemoral, the saphenopopliteal, or the gastropopliteal junction and into those with nonjunctional reflux in the superficial and gastrocnemial veins. Peak velocity and duration of reflux were measured. To examine the recirculation theory, we tested the deep veins by occluding and refluxing saphenous veins 10 cm below the sampling site. RESULTS: Thirteen limbs in 11 patients (9%) were excluded because of previous DVT. Of the remaining 139 limbs, 106 (76%) had junctional reflux. Saphenofemoral junction was involved in 89 limbs (84%), saphenopopliteal junction in 18 (17%), and gastropopliteal junction in 7 (4%). In 33 limbs (24%), reflux was detected in the main trunk or tributaries of the saphenous veins alone with no junctional incompetence. Femoral or popliteal reflux was present in 31 limbs (22%). This reflux was segmental in 27 limbs, and it was limited in the junction in 24 limbs. The mean duration of deep venous reflux was 0.9 seconds, it ranged from 0.6 to 3.7 seconds, and it was significantly shorter than that in the superficial veins (2.6 seconds; P <.0001). In the absence of junctional reflux, the prevalence of deep venous insufficiency (DVI) was significantly lower compared with that in limbs with junctional involvement (2 of 33 vs 29 of 106; P =.038). The mean duration of deep venous reflux in these groups was comparable (0.85 seconds vs 0. 91 seconds; P =.44). Occlusion of the incompetent superficial veins reduced somewhat the duration of the deep venous reflux but did not abolish it (0.88 seconds vs 0.82 seconds; P =.072). The presence of DVI was associated with junctional reflux of high peak velocity and long duration. CONCLUSIONS: The prevalence of DVI in patients with primary superficial venous reflux and without history of DVT is 22%. However, this reflux is segmental, mainly in the common femoral vein, and is of short duration. It is associated with the presence of junctional incompetence that has a high peak velocity and long duration. These findings may explain why surgical correction of superficial reflux abolishes DVI.     

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.     

Deep axial reflux, an important contributor to skin changes or ulcer in chronic venous disease

OBJECTIVE: We undertook this cross-sectional study to investigate the distribution of venous reflux and effect of axial reflux in superficial and deep veins and to determine the clinical value of quantifying peak reverse flow velocity and reflux time in limbs with chronic venous disease. PATIENTS AND METHODS: Four hundred one legs (127 with skin changes, 274 without skin changes) in 272 patients were examined with duplex ultrasound scanning, and peak reverse flow velocity and reflux time were measured. Both parameters were graded on a scale of 0 to 4. The sum of reverse flow scores was calculated from seven venous segments, three in superficial veins (great saphenous vein at saphenofemoral junction, great saphenous vein below knee, small saphenous vein) and four in deep veins (common femoral vein, femoral vein, deep femoral vein, popliteal vein). Axial reflux was defined as reflux in the great saphenous vein above and below the knee or in the femoral vein to the popliteal vein below the knee. Reflux parameters and presence or absence of axial reflux in superficial or deep veins were correlated with prevalence of skin changes or ulcer (CEAP class 4-6). RESULTS: The most common anatomic presentation was incompetence in all three systems (superficial, deep, perforator; 46%) or in superficial or perforator veins (28%). Isolated reflux in one system only was rare (15%; superficial, 28 legs; deep, 14 legs; perforator, 18 legs). Deep venous incompetence was present in 244 legs (61%). If common femoral vein reflux was excluded, prevalence of deep venous incompetence was 52%. The cause, according to findings at duplex ultrasound scanning, was primary in 302 legs (75%) and secondary in 99 legs (25%). Presence of axial deep venous reflux increased significantly with prevalence of skin changes or ulcer (C4-C6; odds ratio [OR], 2.7; 95% confidence interval [CI], 1.56-4.67). Of 110 extremities with incompetent popliteal vein, 81 legs had even femoral vein reflux, with significantly more skin changes or ulcer, compared with 29 legs with popliteal reflux alone (P =.025). Legs with skin changes or ulcer had significantly higher total peak reverse flow velocity (P =.006), but the difference for total reflux time did not reach significance (P =.084) compared with legs without skin changes. In contrast, presence of axial reflux in superficial veins did not increase prevalence of skin changes (OR, 0.73; 95% CI, 0.44-1.2). Incompetent perforator veins were observed as often in patients with no skin changes (C0-C3, 215 of 274, 78%) as in patients with skin changes (C4-C6, 106 of 127, 83%; P =.25). CONCLUSION: Continuous axial deep venous reflux is a major contributor to increased prevalence of skin changes or ulcer in patients with chronic venous disease compared with segmental deep venous reflux above or below the knee only. The total peak reverse flow velocity score is significantly higher in patients with skin changes or ulcer. It is questionable whether peak reverse flow velocity and reflux time can be used to quantify venous reflux; however, if they are used, peak reverse flow velocity seems to reflect venous malfunction more appropriately.     

Distribution of venous valvular incompetence in patients with the postphlebitic syndrome

The records of 122 patients who underwent Doppler evaluation for the postphlebitic syndrome were reviewed to determine the relationship between location of venous valvular incompetence and severity of clinical signs. Categorized according to the most severe physical finding, there were 35 limbs with perimalleolar ulcers, 113 with stasis pigmentation, 26 with swelling, and 70 with no overt signs. Incompetent veins, either deep or superficial, were present in 93% of the symptomatic and 59% of the asymptomatic limbs. Proximal (iliofemoral) deep venous incompetence was not strongly correlated with disease severity (p less than 0.10), but distal (popliteotibial) deep venous and superficial venous incompetence were (both, p less than 0.0005). The relative frequency of isolated proximal incompetence appeared to diminish with increasing disease severity; whereas that of distal incompetence, with or without associated proximal venous incompetence, increased. Isolated proximal venous incompetence was found in only 5% of limbs with severe disease (ulcers or pigmentation). In limbs with severe signs, distal venous incompetence was present in 67% of those with proximal venous incompetence and in 57% of those in which the proximal valves were competent. These findings cast doubt on the potential value of proximal venous valvular reconstruction, especially in limbs with combined proximal and distal insufficiency.     

Ambulatory venous pressure revisited

PURPOSE: The purpose of this study was to describe a method for measuring the deep venous pressure changes in the lower extremity and compare it with those obtained in the dorsal foot vein. METHODS: After cannulation of the posterior tibial vein, a catheter with a pressure transducer in its tip was inserted and placed at the knee joint level. The dorsal foot vein was also cannulated. Pressures were recorded simultaneously at both sites during toe stands and repeated with the probe in the upper, middle, and lower calf. RESULTS: The study was performed in 45 patients with signs and symptoms of chronic venous insufficiency. Duplex Doppler scanning and ascending and descending venography performed before pressure measurements revealed saphenous vein incompetence in 11 lower extremities, incompetent perforators in 11 extremities (eight were combined with saphenous incompetence), and marked compression of popliteal vein with plantar flexion in 28 extremities. No significant deep axial reflux was observed on duplex Doppler examination or descending venography. No morphologic outflow obstruction was detected. The mean deep pressure at the knee joint level fell during toe stands, -15% +/- 27 (SD), and the mean dorsal foot vein pressure drop was even more marked, -75% +/- 22 (SD). Although the exercise pressure in the dorsal foot vein decreased in all patients (range, 13-90% drop), the popliteal vein pressure increased (4-72%) in nine limbs, decreased only marginally if at all in 15 limbs (0-15%), and fell more markedly in 21 extremities (22-65%). Deep vein recovery time was considerably shorter overall as compared with the findings by the dorsal vein measurement. In the comparison of limbs with and without superficial reflux, the recovery times in the deep system were significantly shorter in limbs with superficial incompetence. CONCLUSION: Ambulatory dorsal foot venous pressure is not always accurate in detecting changes in the pressure of the tibial and popliteal veins. Although dorsal foot venous pressure may be normal, deep venous pressure may decrease to a lesser degree or even increase.     

Hemodynamic assessement of chronic venous insufficiency

To study the pathogenesis of chronic venous insufficiency (CVI), photoplethysmography and strain-gauge plethysmography were simultaneously performed in 84 patients. Of the 128 limbs studied, 24 were normal, 64 had primary varicose veins and 40 had post-thrombotic syndrome. Venography was also performed in all patients. The results of this study indicate that reflux in the superficial veins is the main pathophysiology involved in the development of CVI, though incompetence of the perforators and deep veins plays some role. In post-thrombotic syndrome, however, CVI is mainly a sequel of deep venous incompetence, the condition being complicated by incompetent perforators and superficial venous reflux.     

Treatment of superficial and perforator venous incompetence without deep venous insufficiency: is routine perforator ligation necessary?

PURPOSE: We investigated whether routine ligation of incompetent perforator veins is necessary in treatment of symptomatic chronic venous insufficiency (CVI) due to combined superficial and perforator vein incompetence, without deep venous insufficiency. METHODS: This was a retrospective review of prospectively collected data. Twenty-four limbs with both superficial and perforator venous incompetence but no deep venous insufficiency were identified at venous duplex scanning. Air plethysmography (APG) was performed preoperatively, to obtain venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) of the affected limb. Saphenous vein stripping from the groin to knee and powered transilluminated phlebectomy for varicosity ablation were performed in all patients. Postoperatively, all patients underwent duplex scanning and APG to determine the status of the perforator veins and hemodynamic improvement from surgery. RESULTS: Average patient age was 55.8 years; 62% of patients were women. CVI was class 3 in 4 limbs, class 4 in 12 limbs, and class 5 and class 6 in 4 limbs each. Postoperative duplex scans demonstrated that 71% of previously incompetent perforator vessels were now competent or absent. Significant improvement in all APG values was documented after superficial surgery. VFI improved from 6.0 +/- 2.9 preoperatively to 2.2 +/- 1.3 after surgery (P <.001); EF improved from 56.3 +/- 18 to 62 +/- 21 (P =.02); and RVF improved from 40.1 +/- 19 to 28.3 +/- 18 (P =.009). Mean preoperative symptom score (5.3 +/- 1.9) was significantly improved at mean follow-up of 18.3 months (1.4 +/- 1.2; P <.001). CONCLUSION: Patients with superficial and perforator vein incompetence and a normal deep venous system experienced significant improvement in APG-measured hemodynamic parameters and clinical symptom score after superficial ablative surgery alone. This suggests that ligation of the perforator veins can be reserved for patients with persistent incompetent perforator vessels, with abnormal hemodynamic parameters or continued symptoms after superficial ablative surgery.     

Air plethysmographic assessment of external valvuloplasty in patients with valvular incompetence of the saphenous and deep veins

PURPOSE: The indications for deep venous valvuloplasty remain controversial in patients with incompetent deep vein valves associated with primary varicose veins. The purpose of this study was to evaluate the usefulness of external femoral valvuloplasty performed simultaneously with varicose vein surgery from the standpoint of venous function determined with air plethysmography. PATIENTS AND METHODS: Thirty-one limbs of 25 patients (12 men, 13 women; mean age, 56.3 years; range, 33 to 80 years) with chronic venous insufficiency caused by valvular incompetence of both deep veins and saphenous veins were studied in a prospective, nonrandomized fashion. Descending phlebography showed moderate to severe reflux of grade 3 or 4 with Herman and Kistner classifications. Clinical severity of disease was CEAP classification 2S (in six limbs), classification 3 (in three limbs), classification 4 (in 16 limbs), classification 5 (in two limbs), and classification 6 (in four limbs). We performed superficial venous surgery alone in 14 limbs (control group), which consisted of stripping or ligation of incompetent saphenous veins and ligation of all incompetent perforators. In the remaining 17 limbs (study group), we performed superficial venous surgery simultaneously with external valvuloplasty of the femoral vein with intraoperative endoscopic observation. Venous reflux of the limbs was evaluated with air plethysmographic examination before surgery and at 1, 6, 12, and 24 months after surgery in both groups. RESULTS: Preoperative venous filling index (mean +/- standard deviation) in the control and study groups was 9.4 +/- 3.8 mL/min and 8.8 +/- 3.5 mL/min, respectively (not significant), and it decreased to 7.0 +/- 3.6 mL/min (P <.01) and 2.8 +/- 1.0 mL/min (P <.01), respectively, 1 month after surgery. Postoperative index values in the study group were significantly lower than values in the control group (P <.01), and this difference continued for more than 2 years after surgery (P <.05). After a follow-up period of 12 to 37 months (average, 25 months), the venous clinical severity score was higher in the control group (3.4 +/- 1.7) than in the study group (2.1 +/- 0.3; P <.05), and the venous disability score was higher in the control group (1.4 +/- 0.6) than in the study group (0.8 +/- 0.8; P <.05). CONCLUSION: Although further follow-up study is necessary, these results point to the functional and clinical usefulness of femoral valvuloplasty performed simultaneously with varicose vein surgery in patients with moderate to severe deep venous reflux. The venous filling index obtained with air plethysmography is an excellent predictor of the clinical severity of the disease and of postoperative clinical results.     

Hemodynamic assessment of chronic venous insufficiency

To study the pathogenesis of chronic venous insufficiency (CVI), photoplethysmography and strain-gauge plethysmography were simultaneously performed in 84 patients. Of the 128 limbs studied, 24 were normal, 64 had primary varicose veins and 40 had post-thrombotic syndrome. Venography was also performed in all patients. The results of this study indicate that reflux in the superficial veins is the main pathophysiology involved in the development of CVI, though incompetence of the perforators and deep veins plays some role. In post-thrombotic syndrome, however, CVI is mainly a sequel of deep venous incompetence, the condition being complicated by incompetent perforators and superficial venous reflux.     

Recurrent varicose veins following high ligation of long saphenous vein: a duplex ultrasound study

Duplex scanning was used to study recurrent varicose veins in 244 limbs with previous high ligation of the long saphenous vein. The recurrent varicose veins were classified into two types according to the presence or absence of a residual long saphenous vein. Varicose veins with a residual long saphenous vein (type I) occurred in 168 limbs (68.9%). A residual long saphenous vein with an incompetent saphenofemoral junction was present in 125 limbs and one without any residual saphenofemoral junction in 43 limbs. Besides the presence of an incompetent long saphenous vein in this group, an incompetent short saphenous vein was detected in 26 limbs, incompetent perforating vein(s) in 45 limbs and incompetent deep veins in 26 limbs. Varicose veins without a residual long saphenous vein (type II) occurred in 76 limbs (31.1%). An incompetent short saphenous vein was demonstrated in 44 limbs, incompetent perforating vein(s) in 18 limbs and incompetent deep veins in 32 limbs. Of the total 244 limbs with recurrent varicose veins, long saphenous vein incompetence was involved in 168 (68.9%), short saphenous vein incompetence in 70 (28.7%), perforating vein incompetence in 63 (25.8%) and deep venous incompetence in 58 (23.8%). Although saphenofemoral junction incompetence was found to be the main source of recurrence, a segment of incompetent residual long saphenous vein, an incompetent short saphenous vein, perforating vein and deep venous system incompetence are other common sources of recurrence. A precise assessment to identify underlying venous incompetence is important for the management of recurrent varicose veins.     

Haemodynamic and clinical impact of superficial, deep and perforator vein incompetence.

OBJECTIVE: The purpose of this study was to assess the effect of venous incompetence of the deep, superficial and perforator veins combined (i.e. multi-system incompetence) on the venous haemodynamics and clinical condition of limbs with chronic venous disease (CVD). METHODS: One hundred and thirty two limbs (16-C(1); 30-C(2); 20-C(3); 25-C(4); 21-C(5); 20-C(6)) of 121 patients were studied. We excluded those with previous venous surgery/sclerotherapy, peripheral arterial disease, recent deep vein thrombosis (< or =6 months), or inability to comply with the tests. The CEAP clinical class was assessed. Duplex ultrasonography (ultrasound) enabled classification according to: the presence of superficial([S]) (+/- perforator([P])) or deep([D]) (+/-S, +/-P) reflux (>.5s); the number of incompetent venous systems (single-system([S/P/D]), dual-system([S+P/S+D/P+D]), or triple-system([S+P+D])), and the number of incompetent perforators([0/1/2/> or =3]). The amount of reflux (Venous Filling Index([VFI])); calf pump Ejection Fraction([EF]), and Residual Volume Fraction([RVF]) were studied with air-plethysmography. RESULTS: VFI in limbs with triple-system incompetence (VFI median 6.68 [IQR: 4.7-9.7]ml/s) was higher than in limbs with dual-system incompetence (4.5 [2.1-7.4]ml/s), and VFI in the latter was higher than in limbs with single-system incompetence (1.3 [0.69-2.3]ml/s)(p<0.01 Kruskal-Wallis). Although EF changes were small, RVF in limbs with triple-incompetence (39 [30-51] %) was higher than in single-system incompetence (26 [16-33] %)(p<0.01 Mann-Whitney). Limbs with superficial (+/-P) incompetence had a lower VFI (p<0.01) and RVF (p<0.02) than limbs with deep (+/-S+/-P) incompetence, and limbs with > or =2 incompetent perforator veins had a higher VFI (p<0.04) than those without perforators. All limbs with single-system incompetence were C(1-3,) whereas 78% of those with triple-incompetence were C(4-6) (p<0.01). The number of incompetent systems increased with clinical class (p<0.01). CONCLUSIONS: The frequency of incompetence of more than one venous system increased with the clinical severity of venous disease and was accompanied by a 5-fold increase in the amount of reflux and a 50% rise in the RVF. The number of incompetent perforators per limb increased with the amount of reflux. The number of incompetent venous systems (superficial, deep, perforator) and perforator veins can be assessed by duplex ultrasound giving an objective indication of the functional severity of venous disease. In this way duplex ultrasound could be used to grade venous function in clinical practice as an alternative to APG measures which are less widely available.     

Status of the valves in the superficial and deep venous system in chronic venous disease

The relationship between the functional status of the venous valves in the superficial and deep veins and ulceration was evaluated in 42 patients. Twenty-five patients had ulcers, 12 of these patients had a history of previous deep venous thrombosis and 13 of these patients denied such an event. Seventeen patients had normal ankle skin, 10 of these patients had a documented history of deep vein thrombosis and seven of these patients had varicose veins only. An ultrasonic duplex scanner was used to document the presence of reflux in all segments of the superficial and deep system. In the entire group of 25 limbs with ulceration, valvular incompetence was noted in 22 limbs at levels involving segments that communicated with the ulcer-bearing area. Of the 17 limbs with normal ankle skin, in only two instances was a single segment of posterior tibial vein in midcalf found to be incompetent. For those patients with normal ankle skin and a history of varicose veins, the deep veins below the common femoral vein level were always competent.     

Hemodynamic assessment of femoropopliteal venous reflux in patients with primary varicose veins

Purpose: The aim of this study was to assess the anatomic distribution and extent of deep venous reflux in patients with primary varicose veins (PVVs) and to investigate its influence on venous hemodynamics.Methods: Femoropopliteal venous reflux was examined using duplex color Doppler ultrasonography in 356 limbs with PVVs in 240 patients. Photoplethysmography (PPG) was performed using above-knee and below-knee tourniquets to determine the contributions of deep and superficial venous insufficiency.Results: Of 356 limbs with PVVs, 61 (17.1%) had femoropopliteal venous reflux, 42 (11.8%) had superficial femoral venous reflux alone, and 57 (16.0%) had popliteal venous reflux alone. Femoropopliteal venous reflux was associated significantly with clinical symptoms and shortened the half venous refilling time measured by PPG, especially in the presence of incompetent perforating veins. These findings were obtained regardless of the presence of long saphenous vein reflux.Conclusions: Femoropopliteal venous reflux associated with PVVs plays an important role in the pathophysiologic mechanism of venous stasis and influences venous hemodynamics in the presence of incompetent perforating veins and short saphenous vein. (J Vasc Surg 1997 26:260-4.)     

Reflux from thigh to calf, the major pathology in chronic venous ulcer disease: surgery indicated in the majority of patients

The aim of this study was to define the underlying anatomical and pathophysiological conditions in limbs with venous ulcers in order to get information for the most appropriate treatment selection. Ninety-eight limbs (83 patients, 59 men), with active chronic venous ulcers, were analyzed retrospectively and classified according to the CEAP (clinical, etiological, anatomical, and pathophysiological) classification. Duplex-ultrasound was performed in all patients, while air-plethysmography and venography were performed selectively on potential candidates for deep venous reconstruction. Sixty-six ulcers were primary in origin and 32 were secondary. Reflux was present in all limbs except 1. Isolated reflux in 1 system (superficial = 3, deep = 4, perforator = 3) was seen in 10 legs (10%), while incompetence in all 3 systems was seen in 51 legs (52%). Superficial reflux with or without involvement of other systems was seen in 84 legs (86%), 72 legs (73%) had deep reflux with or without involvement of other systems, and incompetent perforator veins were identified in 79 limbs (81%). Axial reflux (continuous reverse flow from the groin region to below knee) was found in 77 limbs (79%). The femoral vein was the single most common deep venous segment in which either reflux or obstruction was found. Axial distribution of disease was found in the majority of cases and no patient had isolated deep venous incompetence below knee. Primary disease was the predominant etiologic cause and reflux was the main pathophysiological finding. Practically all patients were found to have 1 or more sites of reflux or obstruction that could benefit from operative treatment.     

Errors in the differential diagnosis of incompetence of the popliteal vein and short saphenous vein by Doppler ultrasound

Doppler Ultrasound is now routinely used to demonstrate valvular reflux in the venous system. Incompetence detected at the back of the knee is located either in the short saphenous vein or in the popliteal vein. Whether the incompetence is in the deep or superficial venous system can be differentiated by digital compression over the short saphenous vein in the upper calf; if reflux is abolished then the incompetence is assumed to be in the superficial vein but if it is not prevented it must be in the popliteal vein. Sometimes the reflux is not controlled when the deep system is normal. This has been shown to be due to variations in the anatomy of the short saphenous vein and especially the pattern of its termination. Examples with venography are given, showing that in the presence of incompetence at the sapheno-popliteal junction there may be no reflux in the short saphenous vein; instead the proximal tributaries are involved and reflux in these veins is not controlled by pressure over the short saphenous vein. This explains the false positive diagnosis of valvular incompetence in the popliteal vein.     

In situ hemodynamics of perforating veins in chronic venous insufficiency

PURPOSE: The prevalence of incompetent perforators increases linearly with the clinical severity of chronic venous insufficiency (CVI) and the presence of deep vein incompetence. Putative transmission of deep vein pressure to skin may cause dermal hypoxia and ulceration. Despite extensive prospective interest in the contribution of perforators toward CVI, their hemodynamic role remains controversial. The aim of this prospective study was to determine the in situ hemodynamic performance of incompetent perforating veins across the clinical spectrum of CVI, by means of duplex ultrasonography. METHODS: A total of 265 perforating veins of 90 legs that had clinical signs and symptoms consistent with CVI in 67 patients referred consecutively to the blood flow laboratory were studied. The clinical distribution of the examined limbs was CEAP(0), 10 limbs; CEAP(1-2), 39 limbs; CEAP(3-4), 21 limbs; and CEAP(5-6), 20 limbs. With the use of gated-Doppler ultrasonography on real-time B-mode imaging, the flow velocity waveforms were obtained from the lumen of perforators on release of manual distal leg compression in the sitting position and analyzed for peak and mean velocities, time to peak velocity, volume flow, venous volume displaced outward, and flow pulsatility. The diameter and duration of outward flow (abnormal reflux > 0.5 seconds) were also measured. RESULTS: Incompetent perforators had bigger diameters, higher peak and mean velocities and volume flow, longer time to peak velocity, and bigger venous volume displaced outward (VV(outward)) than competent perforators (all, P <.0001). The diameter of incompetent perforators did not change significantly with CEAP class (all, P >.1). Incompetent thigh and lower-third calf perforators had a significantly bigger diameter than perforators in the upper and middle calf combined (both, P <.05), in incompetent perforators: reflux duration was unaffected by CEAP class or site (P >.3); peak velocity was higher in those in CEAP(3-4) than those in CEAP(1-2) (P =.024); mean velocity in those in CEAP(3-6) during the first second of reflux was twice that of those in CEAP(1-2) (P <.0001); both higher volume flow and VV(outward) were found in the thigh perforators than those in the upper and middle calf thirds (P <.03); CEAP(3-6) volume flow and VV(outward), both in the first second, were twice that in those in CEAP(1-2) (P <.002); flow pulsatility in those in CEAP(5-6) was lower than in those in CEAP(1-2) (P =.014); in deep vein incompetence, higher peak velocity, volume flow, VV(outward), and diameter occurred than in its absence (P <.01). CEAP designation correlated significantly with mean velocity and flow pulsatility, both in the first second (r = 0.3, P <.01). The flow direction pattern in perforator incompetence was uniform across the CVI spectrum: inward on distal manual limb compression, and outward on its release; competent perforators had a smaller percentage of outward flow on limb compression (P <.01). CONCLUSION: In addition to an increase in diameter, perforator incompetence is characterized by significantly higher mean and peak flow velocities, volume flow, and venous volume displaced outward, and a lower flow pulsatility. Differences in early reflux enable a better hemodynamic stratification of incompetent perforators in CVI classes. In the presence of deep reflux, incompetent perforators sustain further hemodynamic impairment. In situ hemodynamics enable quantification of the function of perforators and can be used in the identification of the clinically relevant perforators and the impact of surgery.     

Primary varicose veins: the sapheno-femoral junction, distribution of varicosities and patterns of incompetence.

OBJECTIVE: to determine the patterns of long saphenous vein (LSV) disease in primary varicose veins (VVs). DESIGN: a retrospective analysis of venous duplex scans performed on patients referred for treatment of primary VVs. METHODS: analysis was made of sapheno-femoral junction (SFJ) incompetence, non-SFJ incompetence, segmental and perforating vein incompetence, distribution of varicosities, deep venous insufficiency, and short saphenous incompetence. RESULTS: four hundred and eighty-one patients were assessed (median age 50 (range 12-98) years; male:female ratio 1:1.95), comprising 706 limbs. Forty-six per cent of limbs had a competent SFJ, 64% of which had no incompetent perforating vessels associated. Disease was more widespread when the SFJ was incompetent. Varicosities were most common in the calf, occurring at or below the level of incompetence within the LSV. Incompetent segments occurred most commonly above-knee. There was no obvious correlation between incompetent perforators and distribution of varicosities, or incompetent segments. Short saphenous incompetence and non-SFJ groin recurrence were associated more with a competent SFJ, the converse being true for the Giacomini vein. CONCLUSION: primary VVs develop in isolated segments of the superficial venous system (without connection to the deep system) at, or distal to, the underlying main trunk incompetence, suggesting a process of "spreading incompetence" from one focal point, producing varicosities (mainly in tributaries).     

Surgical correction of recurrent venous ulcer

Seventy-six limbs from 46 patients with comparable superficial and deep venous valve incompetence underwent surgical correction for recurrent venous ulcers of the leg that were refractory to various modes of nonsurgical and surgical treatments. A follow-up of 10 to 73 months (mean = 37 months), revealed the venous ulcer healed with perforator ligation and saphenous vein stripping in 14 of 33 (44%), stripping plus valvuloplasty 17 of 21 (80%), stripping plus vein transposition 11 of 14 (78%) and stripping plus valve transplantation 6 of 8 (75%). In patients with incompetent deep venous valve and perforators, the disassociation of the superficial from the deep venous system (stripping) plus correction of the deep venous valvular incompetence (valvuloplasty, transposition or valve transplant) produced superior results in the treatment of recurrent venous ulcer when compared to perforator ligation and saphenous vein stripping alone (p less than 0.005). Adjunctive usage of elastic stockings and intermittent compression pneumatic boots in the perioperative period was helpful in controlling leg swelling and promoting wound healing.     

Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR study)--haemodynamic and anatomical changes

BACKGROUND: The aim of this study was to evaluate the anatomical and haemodynamic effects of superficial venous surgery and compression on legs with chronic venous ulceration. METHODS: Legs with open or recently healed ulceration and saphenous reflux were treated with multilayer compression bandaging or superficial venous surgery plus compression as part of a clinical trial. Venous duplex imaging was performed before treatment and at 1 year. Legs were stratified before surgery as having no deep reflux, segmental deep reflux or total deep reflux. Venous refill times (VRTs) were calculated before treatment and at 1 year using photoplethysmography, with and without a narrow below-knee cuff inflated to 80 mmHg. RESULTS: Of 214 legs investigated, 112 were treated with compression and 102 with compression plus surgery. Saphenous surgery abolished deep reflux in ten of 22 legs with segmental deep reflux and three of 17 with total deep reflux. Overall median (range) VRT increased from 10 (3-48) to 15 (4-48) s 1 year after surgery (P < 0.001). Preoperative change in VRT on application of a below-knee tourniquet correlated with actual change in VRT following surgery. CONCLUSION: Superficial venous surgery resulted in a significant haemodynamic benefit for legs with venous ulceration despite co-existent deep reflux; residual saphenous reflux was common.     

Valvular incompetence in superficial, deep and perforator veins of limbs with varicose veins

Venous valvular incompetence was investigated with Doppler technique in 296 limbs with untreated primary varicose veins. Partial or complete insufficiency of the long saphenous vein was found in 95%. Six patterns of incompetence of this vein could be distinguished. Insufficiency of the short saphenous vein was present in 15% of the limbs and perforator incompetence in 45%. Femoral and/or popliteal vein reflux was found in 20% of the limbs. In eight limbs (2.7%) with verified primary deep venous insufficiency there was a moderate or severe degree of femoral and popliteal venous reflux. Skin changes secondary to the venous disease were present in 18% of the limbs, mainly those with incompetence of perforator and long saphenous veins. Doppler investigation of varicose limbs give valuable information and can be recommended as a standard pre-treatment test.