Surgical management of deep venous reflux

Axial deep venous reflux can be found in the majority of extremities with advanced skin changes and ulceration. It frequently is associated with recurrent disease and tends to progress with time. More than 30 years' experience with deep venous reconstructive surgery, as well as recent advances in diagnostic imaging, makes possible the rational use of such techniques in the management of chronic venous insufficiency. This report reviews the role of deep venous reflux in the natural history and progression of venous disease, the options for surgical correction of deep venous reflux, the current diagnostic abilities and limitations, and the results of surgical interventions.     

Clinical presentation and venous severity scoring of patients with extended deep axial venous reflux

BACKGROUND: The objective of this study was to evaluate the prevalence and profile of patients presenting with chronic venous insufficiency (class C3-C6) and cascading deep venous reflux involving femoral, popliteal, and crural veins to the ankle. METHODS: From September 2001 to April 2004, 2,894 patients were referred to our center for possible venous disorders. The superficial, deep, and perforator veins of both legs were investigated with color duplex scanning. The criterion for inclusion in this study was the existence of cascading deep venous reflux involving the femoral, popliteal, and crural veins to the ankle whose duration had to be longer than 1 second for the femoropopliteal vein and longer than 0.5 seconds for the crural vein. The advanced CEAP classification, the Venous Clinical Severity Score (VCSS), the Venous Segmental Disease Score (reflux; VSDS), and the Venous Disability Score (VDS) were used. RESULTS: Seventy-one limbs in 60 patients were identified. Eleven limbs (15.5%) were classified as C3, 36 (50.7%) as C4, 21 (29.6%) as C5, and 3 (4.2%) as C6. A primary etiology was identified in 11 (15.5%) limbs, and a postthrombotic etiology was identified in 60 limbs (84.5%). In the latter group, all but four patients were aware that they had had a previous deep venous thrombosis. In addition to femoropopliteal and calf veins, reflux was present in the common femoral vein in 60 (84.5%), the deep femoral vein in 27 (38%), and the muscular calf veins in 62 (87.3%). Incompetent perforator veins were identified in 53 (74.6%) limbs. Fifty-one (71.8%) limbs had a combination of superficial venous insufficiency (AS(2), AS(2,3), AS(4), or their combination) previously treated or present. Of these, 11 had primary etiology alone, and 40 had a secondary etiology with or without primary disease. Means and 95% confidence intervals of the VCSS, VSDS, and VDS were 9.72 (8.91-10.53), 7.2 (6.97-7.42), and 1.08 (0.83-1.32), respectively. A significant increase in the VCSS and in the VSDS (P < .0001) paralleled the CEAP clinical class. The VDS was higher in the C3 and C6 classes but did not reach significance. There was a significant link between the pain magnitude in the VCSS and the VDS (P < .0001). Severity of pain and high VDS did not depend on the wearing of elastic compression stockings. VCSS increased significantly according to the presence of an incompetent perforator vein (P < .05) and/or reflux in the deep femoral vein (P < .05). CONCLUSIONS: This study confirmed the value of the Venous Severity Score as an instrument for evaluation of chronic venous insufficiency. A significant increase in the VCSS and VSDS paralleled CEAP clinical class; VDS was higher in classes C3 and C6 without reaching significance, probably because of the small size of the samples. Some clinical and anatomic features need to be clarified to facilitate scoring.     

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.     

Correction of lower extremity deep venous incompetence by ablation of superficial venous reflux

Chronic venous insufficiency which produces lipodermatosclerosis, varicosities, or ulceration, is frequently caused by superficial venous reflux and deep venous incompetence. The anatomy of venous insufficiency has been clarified with duplex ultrasound, thus allowing appropriately directed therapy. However, postoperative venous physiology in patients undergoing superficial venous ablation has been infrequently reported. This study was undertaken to document the effect of superficial venous ablation on deep venous reflux. Between April 1994 and May 1995, 45 patients were examined preoperatively with duplex ultrasound. All patients had symptomatic venous insufficiency and were found to have greater saphenous vein reflux. Clinical classification of venous insufficiency (according to the criteria of the joint councils of the vascular societies) included class I in 30 patients, class II in 12, and class III in 3. Seventeen patients (38%) had reflux in the femoral venous system in addition to superficial reflux. All patients underwent removal of the proximal greater saphenous vein in concert with multiple stab avulsions of identified varicosities. Postoperative interrogation of the venous system revealed that in 16 (94%) of 17 patients, coexistent femoral venous insufficiency completely resolved. Thus ablation of superficial venous reflux eliminated incompetence in the deep venous system in patients with combined disease. These preliminary results suggest that superficial venous incompetence may be a cause of deep venous insufficiency. Whereas alternative methods to correct deep venous insufficiency have met with limited success, it appears that saphenectomy (when combined disease is present) may be effective in correction of deep venous reflux.Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995.     

Role of superficial venous surgery in patients with combined superficial and segmental deep venous reflux.

OBJECTIVES: superficial venous surgery heals chronic venous ulceration (CVU) in the majority of patients with isolated superficial venous reflux (SVR). This study examines the role of superficial venous surgery in patients with combined SVR and segmental deep venous reflux (DVR). METHODS: combined SVR and segmental DVR was diagnosed by venous duplex in 53 limbs in 49 patients (24 men and 25 women of median age 66, range 27-90, years). Fourteen limbs had varicose veins (CEAP class 2-4) and 39 (74%) had active CVU (CEAP class 6). Duplex ultrasound was performed before and three months after local anaesthetic superficial venous surgery. Perforator vein surgery, skin grafting and compression bandaging or hosiery were not used. RESULTS: forty-two limbs with long saphenous vein (LSV) reflux underwent sapheno-femoral disconnection, 10 with short saphenous vein (SSV) reflux underwent sapheno-popliteal disconnection and one limb with LSV and SSV reflux had sapheno-femoral and sapheno-popliteal disconnection. Segmental DVR was confined to the superficial femoral vein (SFV) in 16 limbs, below knee popliteal vein (BKPV) in 25 and gastrocnemius vein (GV) in 12 limbs. Overall, duplex demonstrated post-operative resolution of segmental DVR in 26 of 53 (49%) limbs. Resolution of segmental SFV reflux occurred in 12 of 16 (75%) limbs compared with 14 of 37 (38%) limbs with segmental BKPV or GV reflux (p=0.018). Segmental DVR resolved in 19 of 39 (49%) limbs with CVU and ulcer healing occurred in 30 of 39 (77%) limbs at 12 months with a median time to healing of 61 (range 14-352) days. Segmental DVR resolved in 14 of 30 (47%) limbs with a healed ulcer: 7 of 9 (78%) limbs with SFV and 7 of 21 (33%) with BKPV or GV reflux (p=0.046). CONCLUSIONS: these data demonstrate that in patients with combined SVR and segmental DVR, superficial venous surgery alone corrects DVR in almost 50% of limbs and is associated with ulcer healing in 77% of limbs at 12 months. These findings suggest an extended role for superficial venous surgery in the management of patients with complicated venous disease.     

The effect of long saphenous vein stripping on deep venous reflux.

BACKGROUND: The addition of long saphenous vein (LSV) stripping to sapheno-femoral junction (SFJ) disconnection and multiple stab avulsions (MSAs) in the course of varicose vein (VV) surgery is associated with a significant reduction in recurrence, and a significant improvement in quality of life. It is hypothesised that these benefits relate, at least in part, to a favourable effect of stripping on deep venous reflux. OBJECTIVE: To examine the effect of long saphenous vein (LSV) stripping on deep venous reflux (DVR). METHODS: This was prospective study of 62 consecutive patients (77 limbs) CEAP class 2-6, undergoing SFJ disconnection and MSAs, with and without successful stripping of the LSV to the knee. A duplex ultrasound examination was performed pre-operatively and at a median (IQR) of 24 (23-25) months post-operatively. Completely stripped limbs were defined as those in whom complete stripping of the LSV to the knee was confirmed on post-operative duplex. Reflux >/=0.5 s. was considered pathological. RESULTS: Pre-operatively, 32 (42%) limbs had deep venous reflux (DVR). Post-operative duplex at 24 months revealed that the LSV had been completely stripped in 29 (38%) limbs. In patients with pre-operative DVR, complete stripping was associated with a significant reduction in the prevalence of superficial femoral vein (SFV) (p<0.001) and popliteal vein (PV) (p=0.016), McNemar test) on post-operative duplex. By contrast, in patients without pre-operative DVR, incomplete stripping was associated the development of SFV (p=0.031) and PV (p=0.008) reflux. CONCLUSIONS: Complete LSV stripping abolishes DVR in a significant proportion of limbs, whereas failure to strip is frequently associated with the development of new DVR. These data support for routine stripping and suggest that the benefits of stripping may relate, at least in part, to a favourable impact on deep venous function.     

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

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

Quantitative assessment of the degree of deep venous reflux of the lower extremities

OBJECTIVE: We sought to quantitatively evaluate the degree of deep venous reflux of the lower extremities using colour Doppler velocity profile (CDVP) technology. METHODS: Deep venous reflux volume was examined using CDVP in 79 limbs of 66 patients who were admitted to our hospital between July 1999 and July 2000 with primary, deep venous, valvular incompetence. Reflux data were statistically described and analyzed. RESULTS: Of 79 limbs, 20 had grade I reflux, with a mean reflux volume of 29.79 +/- 5.89 mL/min; 19 had grade II reflux, mean reflux volume, 43.87 +/- 4.86 mL/min; 23 had grade III reflux, mean reflux volume, 70.67 +/- 5.77 mL/min; and 17 had grade IV reflux, mean reflux volume, 105.07 +/- 14.8 mL/min. There were significant differences among grades I, II, III and IV (p < 0.05), except between grades I and II (p > 0.05) for analysis of variance and Student-Newman-Keuls analysis, although the 95% confidence interval (CI) of grade I was different from grade II. Every degree of reflux volume showed close correlation with the reflux index. Other indices were less sensitive. CONCLUSIONS: Venous reflux volume is a more accurate non-invasive quantitative assessment of the degree of deep venous reflux in the lower extremities than current methods.     

Reconstructive surgery for deep venous reflux: a report on 144 cases

This retrospective study was conducted on 144 lower extremities (133 patients) with deep venous reflux treated with surgery to restore venous valvular function. Clinically, 51% of patients were in class C5-C6, and based on etiology, patients were equally divided into primary and secondary venous disease. Four surgical procedures were used: valvuloplasty (n=85), transposition (n=18), transplantation (n=32), or Psathakis' technique II (n=9). The procedure chosen was determined mainly by the feasibility of the technique in the above-mentioned preferred order. Thus, 76% of valvuloplasties were performed for primary venous insufficiency. A postoperative venography routinely performed soon after surgery demonstrated a large number of segmental thromboses (20.3%). Their number was statistically different in primary and secondary (PTS) venous disease, respectively 8.8 vs 32.3%. Clinical and hemodynamic results were evaluated (duration of follow-up: 12-168 months) based on etiology and type of procedure. A correlation was established between clinical result (venous ulcer) and efficacy of valvular reconstruction. The latter was satisfactory in valvuloplasties (P=0.005) but not in venous transfer (P=0.35). Overall results were better for primary venous insufficiency than in postthrombotic syndromes (P=0.03).     

浅静脉剥脱术治疗合并深浅静脉反流的下肢静脉曲张

目的 探讨下肢浅静脉剥脱术对合并深、浅静脉反流的静脉曲张的疗效.方法 2004年1月至2006年12月选取合并深浅静脉反流患者20例共22条下肢,以单纯浅静脉反流患者22例共27条下肢为对照,采用传统静脉剥脱手术方法治疗.以静脉临床严重程度评分(venous clinical severity score,VCSS)临床评分体系以及彩色多普勒超声检查观察二组术前以及术后2年临床症状改善以及深静脉反流程度的变化.结果 深浅静脉反流组和单纯浅静脉反流组术前VCSS分别为(7.1±2.9)分和(6.6±2.0)分,差异无统计学意义(P=0.44).术后两组VCSS分别为(2.3±1.2)分和(1.8±0.8)分,差异无统计学意义(P=0.13).随访两年各组手术前后VCSS评分差异均有统计学意义(P<0.01),2年后超声检查深浅静脉反流组中深静脉反流程度无改变肢体11条,改善7条,加重4条,单纯浅静脉反流组4个肢体出现深静脉反流.结论 浅静脉剥脱术可改善合并深静脉反流患者的临床症状,对深静脉反流总体无影响.     

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目的探讨下肢浅静脉剥脱术后病人深静脉反流程度的变化。方法 2007年1月至2009年1月承德医学院附属医院血管外科收治下肢静脉曲张合并有节段性深静脉反流的病人46例,对其共48条下肢采用传统手术治疗,超声观察下肢深静脉反流程度,应用临床表现严重程度评分(VCSS)评估临床症状的改善情况。结果 42例病人随访2年,术后2年VCSS为1.95±1.78,低于术前(6.33±1.78),差异具有统计学意义(P<0.01)。2年后超声检查深静脉反流程度无改变肢体22条,改善14条,加重6条,手术前后深静脉反流程度差异无统计学意义。不同CEAP分级的反流程度的改善差异无统计学意义(P=0.359)。结论浅静脉剥脱术后能改善伴有深静脉反流病人的临床症状,对部分病人可改善深静脉反流程度,改善程度与CEAP分级不相关。     

Postthrombotic syndrome after isolated calf deep venous thrombosis: the role of popliteal reflux

OBJECTIVE: The purpose of this study was to evaluate the long-term clinical and hemodynamic outcomes after isolated first-time calf deep venous thrombosis (cDVT). METHODS: This retrospective clinical study was set in an academic referral center. From 1990 to 1994, 617 patients were seen with acute DVT. This number included 82 patients with phlebographically confirmed cDVT. Of those patients, 50 attended the clinical assessment 6 to 10 years (mean, 8.4 years) after the acute event. All patients with cDVT underwent treatment with anticoagulant therapy (96% heparin and warfarin, 4% only warfarin). The duration of the heparin treatment was 4.0 to 8.0 days (mean, 6.4 days), and warfarin was given for 2.0 to 7.5 months (mean, 3.4 months). Compression stockings were used regularly (mean, 9.2 months; range, 0.25 to 64 months) in 30% of the patients after acute cDVT. The initial ipsilateral phlebograms were reevaluated to confirm the diagnosis of cDVT without popliteal involvement. The clinical assessment included evaluation of both legs according to CEAP clinical classification C0-6. Bilateral color-flow duplex scan imaging was performed to assess reflux in deep popliteal segments. Photoplethysmographic measurement of venous refilling time was conducted in both legs to observe deep reflux. RESULTS: The mean age was 57 years (range, 30 to 76 years) at the time of the clinical assessment. Cause of acute cDVT was idiopathy in 52%, coagulopathy in 2%, trauma in 10%, immobilization in 22%, and postoperative in 14% of the cases. During the follow-up period, seven recurrent DVTs (14%) were seen. In the clinical assessment, 17 legs (34%) with previous cDVT had skin changes (CEAP C4-6). No active ulcers were found. Contralaterally, the frequency of C4-6 was 10% (n = 5; P <.05). After exclusion of recurrent DVTs, the distribution of the clinical classification still remained the same. Deep popliteal reflux was detected in 20 legs (40%) with previous cDVT. Contralaterally, popliteal reflux was seen in nine cases (18%; P <.05). Plethysmography showed deep reflux in 16 legs (33%) with cDVT and in nine cases (18%) contralaterally (P >.05). A significant association was found between deep popliteal reflux and skin changes (P <.05). CONCLUSION: In the long-term follow-up, cDVT may lead to significant postthrombotic disease. Reflux in the primarily uninvolved popliteal vein is frequent and may be associated with more severe disease.     

Saphenous surgery does not correct perforator incompetence in the presence of deep venous reflux

Purpose: To determine which patients require subfascial endoscopic perforator surgery (SEPS) in addition to saphenous surgery to correct pathologic outward flow within incompetent medial calf perforating veins (IPVs). Methods: Sixty-two limbs of 47 patients undergoing sapheno-femoral ligation, stripping of the long saphenous vein in the thigh, and multiple phlebectomies (n = 51), sapheno-popliteal ligation and multiple phlebectomies (n = 10), or both (n = 1) were examined with color flow duplex ultrasound scan immediately before and a median of 14 weeks (range, 6 to 26 weeks) after the operations. Indications for surgery were varicose veins (n = 47, Clinical, Etiologic, Anatomic, Pathophysiologic grades C_2&3), skin changes (n = 5, C₄), and ulceration (n = 10, C₅). Results: Surgery resulted in a significant reduction in the total number of limbs in which IPVs were imaged (40/62 or 65% preoperatively vs 23/62 or 37% postoperatively, P <.01, χ² test), a significant reduction in the proportion of perforators imaged that were incompetent (68/130 or 52% preoperatively vs 34/120 or 28% postoperatively, P <.01, χ² test), and a reduction in median IPV diameter (4 mm, with a range of 1 to 11 mm preoperatively, vs 3, with a range of 1 to 8 mm postoperatively, P <.01, Mann-Whitney U test). IPVs remained in 8 of 41 (20%) limbs in which main stem reflux was abolished, compared with 15 of 21 (72%) limbs in which superficial or deep reflux remained (P <.01, χ² test). Conclusion: Eradication of main stem saphenous reflux corrects IPV reflux in most cases in which reflux is confined to the superficial system. However, in patients with superficial reflux that persists postoperatively, or when there is coexistent deep venous reflux, saphenous surgery alone fails to correct IPVs reflux. In these circumstances, the only way of reliably correcting pathologic outward flow in medial calf perforating veins is to perform SEPS. (J Vasc Surg 1998;28:834-8.)     

Deep venous thrombosis and superficial venous reflux

OBJECTIVE: Although superficial venous reflux is an important determinant of post-thrombotic skin changes, the origin of this reflux is unknown. The purpose of this study was to evaluate the frequency and etiologic mechanisms of superficial venous reflux after acute deep venous thrombosis (DVT). METHODS: Patients with a documented acute lower extremity DVT were asked to return for serial venous duplex ultrasound examinations at 1 day, 1 week, 1 month, every 3 months for the first year, and every year thereafter. Reflux in the greater saphenous vein (GSV) and lesser saphenous vein (LSV) was assessed by standing distal pneumatic cuff deflation. RESULTS: Sixty-six patients with a DVT in 69 lower extremities were followed up for a mean of 48 (SD +/- 32) months. Initial thrombosis of the GSV was noted in 15 limbs (21.7%). At 8 years, the cumulative incidence of GSV reflux was 77.1% (SE +/- 0.11) in DVT limbs with GSV involvement, 28.9% (+/- 0.09%) in DVT limbs without GSV thrombosis, and 14.8% (+/- 0.05) in uninvolved contralateral limbs (P <.0001). For LSV reflux, the cumulative incidence in DVT limbs was 23.1% (+/- 0.06%) in comparison with 10% (+/- 0.06%) in uninvolved limbs (P =.06). In comparison with uninvolved contralateral limbs, the relative risk of GSV reflux for DVT limbs with and without GSV thrombosis was 8.7 (P <.001) and 1.4 (P =.5), respectively. The relative risk of LSV reflux in thrombosed extremities compared with uninvolved extremities was 3.2 (P =.07). Despite these observations, the fraction of observed GSV reflux that could be attributable to superficial thrombosis was only 49%. CONCLUSIONS: Superficial venous thrombosis frequently accompanies DVT and is associated with development of superficial reflux in most limbs. However, a substantial proportion of observed reflux is not directly associated with thrombosis and develops at a rate equivalent to that in uninvolved limbs.     

Reversal of deep vein reflux after successful stenting in a patient with venous hypertension after thigh access graft creation

Presented here is a case of reversal of deep vein reflux after successful stenting in a patient with venous hypertension and valve incompetence after thigh angioaccess creation. The patient with exhausted upper-extremity access sites underwent a loop graft in the upper thigh. Six months later, the patient developed leg edema and significant femoral vein reflux on duplex ultrasound. Fistulography revealed an iliac vein stenosis, which was treated successfully with stenting. The edema and reflux on duplex promptly resolved. In similar cases, reflux may be a consequence of functional valve incompetence and can be reverted by timely treating the underlying stenosis.     

The venous ulcer and the superficial venous reflux

The management of venous ulcers must take into account the many aspects of the pathology and, overall, the hemodynamic patterns of reflux and the clinical pictures correlated. The most frequent model is represented by a superficial venous reflux that may be successfully treated by surgery with a very high percentage of ulcer healing. Compared to compression therapy, surgery allows a minor percentage of recurrence. Sclerotherapy may represent a valid alternative. The meaning and the treatment of incompetent perforating veins is controversial, but the poor results of conservative treatment justify the disconnection of large perforators in addition to ablation of saphenous reflux.     

股浅静脉瓣膜包窄术治疗下肢深静脉瓣膜功能不全的评价

目的：评价下肢深静脉瓣膜包术的临床应用价值。方法：经静脉造影等检查后,诊断为原发性下肢深静脉瓣膜功能不全,倒流3－4级,其倒流程度为轻度和中度399例（405条患肢）施行手术。结果：至1999年2月,70％患肢已随访3－139个月,平均5年以上,疗效满意占86％,病情好转为12％,无效2％。结论：下肢深静脉瓣膜包窄术有合理的理论基础,操作简便,易于在基层推广。合理选择手术适应证,是手术成功的关键。