The role of perforating vein dissection in the treatment concept of venous ulcers--myths and evidence

Crural ulcers represent the most serious form of chronic venous incompetence (CVI). According to duplex studies superficial venous incompetence predominate in this stage of the disease, but combined refluxes of superficial and deep veins are also common. Despite a positive correlation between the number of incompetent perforators and the stage of CVI isolated incompetence of perforating veins in venous ulcers are rarely found. Additionally, only a minority of incompetent perforators depict larger reflux volumes. Therefore, doubts about a causal role of perforators incompetence in ulcer genesis are justified. According to phlebodynamometric studies the risk of crural ulcer development increases with the degree of hemodynamic compromise. Ulcer healing can only be achieved after complete normalization of ambulatory venous hypertension. In case of superficial refluxes and concomitant incompetence of perforating veins exclusion of the superficial component is sufficient to achieve this goal. Incompetent perforators normalize their function consecutively. In contrast, venous hypertension persists after exclusion of superficial refluxes in case of incompetent perforators and irreversible damage of the deep venous system. Surgical therapy studies exactly reflect the results of these hemodynamic examinations. Therefore, the role of endoscopic subfascial perforator dissection (ESPD) in the treatment of venous ulcers remains unclear. Future therapy studies should take into account that the definite role of ESPD in ulcer healing can only be examined without additional treatment of refluxes in the saphena system. Additionally, all study patients should be classified according to the CEAP nomenclature and Hach's classification of chronic compartment syndrome. Methodological differences in technique and extent of ESPD have also to be taken into account.     

Comparison of skin and muscle biopsies before and after pentoxifylline treatment in patients with leg ulcers due to deep venous incompetence.

The aim of this study was to understand the possible mechanisms by which deep venous insufficiency and venous hypertension are associated with trophic skin changes and ulceration and to explain the therapeutic effect of Pentoxifylline in patients with leg ulcers due to deep venous incompetence. Twenty patients were included in this pilot study. They were graded into two groups: group 1, included 10 patients (5 F and 5 M) with deep venous incompetence and normal arteries; group 2, included 10 patients (1 F and 9 M) with deep venous incompetence and moderate arterial disease. Skin and muscle biopsies were carried out before and after the oral administration of 1,200 mg of Pentoxifylline daily (400 mg t.d.s). The following parameters were investigated by means of light microscopy and immunofluorescence tests: engorgement of venous stroma; decrease of intimal elastica; hyaline degeneration; floccular degeneration; pericapillary fibrin deposits and fibrin degradation products; inflammation and fat necrosis; myofibril degeneration; fibrous scar; regeneration and reconstitution of muscle fibres. The results indicated that local inflammation at the ulcer's area cause accumulation of white blood cells in the capillaries and the interstitial fluid, where there is also accumulation of fibrinogen. These changes may lead to chronic tissue ischaemia and ulceration. The known favourable effect of Pentoxifylline on red cells and leucocyte function as well as its lowering effect on plasma fibrinogen level, may be responsible for the observed therapeutic effect of Pentoxifylline on venous leg ulcers.     

Conception of the venous hemodynamics in the lower extremity

Contradictory reports on the significance of several hemodynamic phenomena, such as femoral vein incompetence and incompetent calf perforators, impede orientation in venous hemodynamics. Venous pressure difference arising between the popliteal and the posterior tibial vein during the activity of the calf muscle venous pump was reported for the first time about 50 years ago, but regrettably, this important discovery continues to be unrespected. The venous pressure difference has since been termed ambulatory pressure gradient and seems to be the key factor triggering the venous reflux in the lower limb as well as the process leading to varicose vein recurrence. On the other hand, simultaneous recordings of the mean venous pressure in the posterior tibial and long saphenous veins demonstrated that the pressure curves have been identical at rest, during ambulation, and in the recovery period, a finding typical of conjoined vessels. Bidirectional flow within calf perforators taking place both in healthy subjects and in patients with varicose veins enables a quick equilibration of pressure changes between deep and superficial veins of the lower leg. Reflux disturbing the venous hemodynamics is in various degrees dependent on the quantity of retrograde flow; abolition of reflux restores normal venous hemodynamics. Reflux in superficial veins, if large enough, may cause the most severe form of chronic venous insufficiency. Femoral vein incompetence and incompetent calf perforators per se do not produce ambulatory venous hypertension and do not cause hemodynamic disturbance. This study discusses the controversial issues, tries to define and appraise the principal hemodynamic phenomena (ambulatory venous hypertension, ambulatory pressure gradient, venous reflux, superficial and deep vein incompetence, incompetent perforators), mentions a possible relation between deep vein incompetence and varicose veins, and attempts to present, based on proved facts, a comprehensive picture of the venous hemodynamics in the lower extremity.     

Deep venous insufficiency of the lower extremities

Lower limbs chronic venous insufficiency (CVI) is a widespread pathologic condition. Prevalence of venous ulcer in Europe ranges between 0.5% and 1.0%. Venous ulceration can be due to insufficiency of the superficial system, although deep venous insufficiency is responsible for 75% of the cases. Morbidity and socio-economic costs are exceedingly high especially because of frequent recurrences. CVI recognises mainly two causes: 1) increased influx, due to arteriovenous fistulas; 2) difficult outflow usually secondary to postphlebitic or primitive valvular incompetence. The prevalence of CVI and venous ulceration is difficult to assess. Surgical treatment tends to cure the underlying hemodynamic problem. Homans in 1916 first introduced surgical treatment of CVI and venous ulceration: excision of the cutaneous lesion and ligature suprafascial of the communicating veins. Since then different various techniques have been introduced in the clinical practice: Linton in 1938 supported subfascial interruption of the perforating veins but still reported a recurrence rate of 47%. Stripping of internal saphenous vein associated with division of perforating veins is still controversial, because lacks evidence of its real effectiveness in preventing recurrences. Felder's surgical technique is preferred by some authors to Linton's technique, because of the possibility to divide and section incompetent perforating veins without a cutaneous incision in the severely diseased postphlebitic tissues. In personal experience (56 patients) treated by Felder's techniques, we reached a cutaneous ulceration healing rate of 36% has been obtained. Subfascial interruption of perforating veins under endoscopic vision associated to the stripping of the internal saphenous vein could be a valuable option in the treatment of CVI because of the shorter duration of the operation and hospital stay and lesser postoperative complications. Repair and/or replacement of deep venous valves, originally described by Kistner in 1968, could be curative of venous hypertension due to primitive valvular insufficiency (primitive or postphlebitic): the same author in 1975 reported positive results (80% at 5 years). Major advantages of indirect valvuloplastic surgical technique are: 1) venotomy is not necessary; 2) it does not introduce extraneous material in the vasal lumen; 3) clamping of the vein is avoided; 4) heparine or other antithrombotic measures are usually not necessary. Although preliminary encouraging results, subsequent clinical experiences have demonstrated that correction of the reflux of the main axial venous system alone is not curative and durable resolution of venous symptoms also depends on the concomitant correction of all incompetent perforating veins. Venous valves transplantation is theoretically good to correct the deep long reflux and to improve calf pump function, although clinical results are still limited and follow-up not prolonged enough in terms of symptoms resolution and complete ulcer healing.     

Comparison of surgical modalities in the treatment of recurrent venous ulcer

Recurrent leg ulcer secondary to superficial and deep venous valve incompetence that are refractory to non-surgical treatment can be healed with the following surgical modalities. Perforator ligation and saphenous vein stripping (PLSVS) healed 4/16 (25%) of the ulcer. PLSVS and correction of deep venous valve incompetence healed 14/16 (87.5%) of the ulcer (p less than 0.005). The mean follow-up was 32 months (8-62 mon). This prospective comparison of the 2 surgical treatments (PLSVS versus PLSVS and correction of deep venous valve) demonstrated that disassociation of the superficial from the deep venous system with PLSVS and correction of the deep valve (valvuloplasty, transposition or valve transplant) produced promising results in the treatment of recurrent venous ulcer. Adjunctive usage of elastic stocking and intermittent compression pneumatic boot to reduce swelling in the paraoperative period improved long term result in venous reconstructive surgery.     

Contemporary treatment of venous lower limb ulcers.

The postphlebitic syndrome is a significant management problem that affects a large number of patients. Primary prophylaxis of deep-vein thrombophlebitis would reduce the risk of developing the postphlebitic syndrome and should be considered in high-risk patients. Patients who have had a phlebitis should be monitored with noninvasive tests of the deep venous circulation for the development of venous valve incompetence. Patients with venous hypertension should be placed in compression stockings to prevent the postphlebitic syndrome. In patients who progress to venous ulceration, several aggressive measures must be undertaken. Systemic treatment includes management of obesity, edema, immobility, poor nutrition, and comorbid illnesses. Some patients may require a short hospitalization of bed rest, lower limb elevation, and daily dressings and wound care. Outpatient therapy requires sustained compression of 35 to 40 mmHg at the ankle for many months to allow the ulcer to heal. The standard bandage material is Unna's boots, which is applied every one to two weeks by a trained nurse. Cadexomer iodide is an effective local treatment that helps debride the ulcer and accelerate healing. Finally, pentoxifylline therapy has also been shown to significantly improve the healing of venous ulcers.     

Chronic leg ulceration in homozygous sickle cell disease: the role of venous incompetence

Chronic leg ulceration is a common cause of morbidity in Jamaican patients with homozygous sickle cell (SS) disease. Ulcers heal more rapidly on bed rest and deteriorate on prolonged standing, suggesting a role of venous hypertension in their persistence. This hypothesis has been tested by Doppler detection of venous competence in SS patients and in matched controls with a normal haemoglobin (AA) genotype in the Jamaican Cohort Study. Venous incompetence was significantly more frequent in SS disease [137/183 (75%)] than in non-pregnant AA controls [53/137 (39%)]. Past or present ulceration occurred in 78 (43%) SS patients, with a highly significant association between leg ulceration and venous incompetence in the same leg (P < 0.001). Prominence and/or varicosities of the veins and spontaneous leg ulcers were more common among patients with multiple sites of incompetence. The association of venous incompetence with chronic leg ulceration identifies a further pathological mechanism contributing to the morbidity of SS disease. The cause of venous incompetence is unknown but the sluggish circulation associated with dependency, turbidity and impaired linear flow at venous valves, hypoxia-induced sickling, the rheological effects of high white cell counts, and activation of components of the coagulation system may all contribute. Venous hypertension in SS patients with leg ulceration suggests that firm elastic supportive dressings might promote healing of chronic leg ulcers.     

External femoral vein valvuloplasty with limited anterior plication (LAP): a 10-year randomized, follow-up study.

The aim of this study was to evaluate the effects after 10 years of external valvuloplasty of the femoral vein (limited anterior plication or LAP). After informed consent patients with venous hypertension due to deep and superficial venous incompetence were randomized into two treatment groups. Both groups were treated with superficial vein surgery (ligation and section of the major incompetent superficial veins). Group 2 was treated with the same procedure and with LAP. External valvuloplasty of the superficial femoral vein was performed with plication of the anterior vein wall after limited dissection of the vein. Results were evaluated with color-duplex scanning and ambulatory venous pressure (AVP) measurements. Endpoints were AVP, refilling time (RT), presence/absence of reflux at the superficial femoral vein, the variation in the diameter of the vein, and quality of life score (QLS). No complications were observed. All femoral veins treated with LAP were competent after 10 years. Significantly lower AVP and longer RT were observed in the LAP group. Also the average diameter of the vein was smaller in the LAP group. Moreover, QLS was significantly better in the LAP group after 10 years. In conclusion, in selected subjects, with moderate deep venous incompetence, functional cusps, or incompetence mainly due to relative enlargement of the femoral vein, LAP may be an effective alternative to external valvuloplasty.     

Management of Varicose Veins From Chronic Venous Insufficiency

Chronic venous insufficiency is a progressive disease, which may require surgical intervention to prevent complications. This study was done to determine the usefulness of a high ligation with sclerotherapy to prevent the return of symptoms. Duplex scanning was used to locate incompetent veins. There was no evidence of incompetent perforating or deep veins in the 322 patients who had 483 high ligations of the greater saphenous vein. Multiple phlebectomies and limited vein stripping were done for large (>20 mm) varicose veins. The clinical, etiologic, anatomic and pathophysiologic (CEAP) score evaluated the severity of venous dysfunctions. Symptoms of leg aches, ankle edema, night cramps or ulceration were evaluated after 1–3 months, and then at 6–12 month intervals. Sclerotherapy of the saphenous vein, using a sodium tetradecyl sulfate solution from 0.1–3.0%, was done if there was no significant improvement of a non-healing ulcer or the recurrence of symptoms. Compression hose, 30–40 mm Hg, was prescribed unless contraindicated by arterial occlusive disease, acute deep vein thrombosis or severe congestive heart disease. After the high ligation, symptoms improved in 212 limbs, were unchanged in 187 limbs and became worse in 84 limbs. After sclerotherapy in 264 limbs, 237 limbs improved, 21 remained unchanged and six became worse. Patients who have varicose veins from superficial venous incompetence can achieve a good long-term outcome with the high ligation procedure. However, it is important to control venous reflux and the related symptoms with sclerotherapy as needed.     

Chronic Venous Insufficiency and Venous Ulceration

OBJECTIVE: To review and summarize the literature on the normal venous circulation of the leg, and the epidemiology, pathophysiology, and treatment of chronic venous insufficiency (CVI).
DATA SOURCES: English-language articles identified through a MEDLINE search (1966 –1996) using the terms venous insufficiency or varicose ulcer and epidemiology, pathophysiology, diagnosis, and clinical trial (pt), and selected cross-references.
STUDY SELECTION: Articles on epidemiology, pathophysiology, and treatment of CVI. Randomized, controlled studies were specifically sought for treatment efficacy.
DATA EXTRACTION: Data were manually extracted from selected studies and reviews; emphasis was placed on information relevant to the general internist.
DATA SYNTHESIS: Chronic venous insufficiency is a common primary care problem associated with significant morbidity and health care costs. The clinical spectrum of disease ranges from minor cosmetic concerns to severe fibrosing panniculitis and ulceration. Duplex Doppler ultrasonography may be the single best test to rule out deep venous thrombosis and other entities that can mimic CVI. Leg elevation and compression stockings are effective treatments for CVI; recalcitrant cases may require intermittent pneumatic compression. Topical antiseptics, antibiotics, enzymes, or growth factors offer no clear advantages in ulcer healing. Ulcer dressings remain a matter of convenience, cost, and physician judgment. The role of surgery in CVI appears to be limited.
CONCLUSIONS: Chronic venous insufficiency is a recalcitrant, recurrent medical problem. This condition can be managed by primary care physicians with relatively inexpensive treatment modalities in association with lifestyle modification.
KEY WORDS: venous circulation, of the leg; venous insufficiency, chronic; varicose ulcer.     

Edema of the lower extremities in the aged patient

Oedema of the lower limbs in the elderly patient are sometimes easy to diagnose in cases of cardiac, renal or hepatic incompetence. But oedema can also be of venous origin: superficial (varicose) incompetence, or deep, with thrombosis (recent or previous] or compression. Certain oedema are of arterial origin when there is pain in the supine position, or after revascularization. Lymphostatic oedema are rarely primary, and most often indicate a pelvic tumour which has escaped diagnosis or has relapsed, sometimes following surgical or ionising treatment. A compressive treatment must take into account the arterial condition of the patient as well as any motor handicaps.     

Management of the postthrombotic syndrome: the Rotterdam approach

The postthrombotic syndrome (PTS) affects the deep venous system, and may also extend to the superficial venous system of the legs in patients with a documented history of deep vein thrombosis. Clinical symptoms of PTS may vary considerably and range from scarcely visible skin changes to changes in pigmentation, pain, discomfort, venous ectasia, edema, and ulceration. Our view based on standard investigations and the proper place of advanced investigations regarding the etiology and pathophysiology of PTS has lead to the Rotterdam approach, incorporating the evidence-based diagnostics and treatments available for PTS. High-quality duplex sonography is mandatory in all patients, providing anatomical and functional (reflux) information on both the deep and superficial venous systems, and non- or partially recanalized veins (occlusion) can also be detected using this technique. If the results of duplex sonography are not clear or a venous desobstruction procedure is to take place, phlebography will be the investigation of choice. There is a lot of evidence that medical elastic stockings (MECS) are effective in the prevention of PTS with documented reflux, obstruction, or both. When prescribing MECS, it is important to examine both elasticity and hysteresis of the fabric of the stockings to apply the correct dynamic pressure for each individual patient. Patients with documented PTS should receive life-long follow-up.     

Venous ablation therapy: indications and outcomes

Venous disease has long been recognized as a progressive, debilitating, and recurrent problem. Until recently, venous insufficiency was often undertreated due to a lack of therapeutic modalities. During the past decade, an explosion in the treatment options has occurred. Endovenous ablation therapy has nearly replaced the conventional surgical treatments for patients with superficial venous insufficiency. Dramatic changes in therapy are also available for deep venous thrombosis but are not the subject of this review. These newer techniques are much less invasive and consequently have reduced risks of wound complications or bleeding. In addition, they can be performed easily in the office setting with local anesthesia. Higher-risk patients can now be considered for these less invasive treatments to reduce their ambulatory venous hypertension. With the lower procedural risks and the dramatically shortened recovery times, earlier intervention can be entertained. This helps prevent the development of venous stasis ulceration and other sequelae of progressive venous insufficiency.     

Physiopathology of venous stasis at the microcirculation level]

The division of the venous circulation in to two sectors, one constituted by the superficial and deep venous trunks (macrocirculation) and the other by the capillaries and precapillary venules (microcirculation), is surely schematical but aids the comprehension of many hemodynamic effects connected to hampered venous return and to the incompetence of the valvular devices. In fact many of the effects of stasis and venous hypertension (oedema, red cell diapedesis, skin dystrophies) cannot be explained merely by hydraulic mechanisms but require a primary alteration of the microvascular wall associated with structural changes of the perivascular connective tissue. The alterations that occur in microcirculation are of the utmost importance in the formation of the venules ulcerations. The passage of fibrinogen through large pores in the venules of the patients affected by venous hypertension derived from venous insufficiency creates a pericapillary fibrin deposition that cannot be removed because of inadequate blood and tissue fibrinolysis. This accumulation acts as a barrier to the diffusion of oxygen and other nutrients, determining a stasis dermatitis that may lead to tissue necrosis and ulceration. The more precise knowledge of the phenomena connected with the venous stasis at the level of microcirculation (pericapillary fibrin deposition, endothelial ischemia, blocked lymphatic drainage) will not only allow a deeper comprehension of the clinical signs but hopefully will lead to a more effective treatment of the postphlebitic syndrome.     

Prevalence of lower extremity venous disease in inflammatory bowel disease.

AIM: Inflammatory bowel disease (IBD) has long been considered a risk factor for venous thromboembolism (VTE). Whereas most patients have persistent venous valvular dysfunction following lower extremity deep venous thrombosis (DVT), we hypothesized that patients with IBD would have an increased prevalence of valvular incompetence and changes of chronic DVT (reduced venous caliber with thickened walls) relative to patients with irritable bowel syndrome (IBS) or normal volunteers. METHODS: Subjects with confirmed IBD, clinical features of IBS or normal volunteers underwent complete, prospective duplex ultrasound assessment of their lower extremity venous vascular system. The sonographer performing the venous study was blinded to the clinical diagnosis of the patients. Valvular incompetence was graded as mild, moderate or severe based on accepted criteria. RESULTS: Eighty patients with IBD (ulcerative colitis, UC: 66; Crohn's disease: 14), 80 patients with IBS, and 80 healthy volunteers agreed to participate. One patient with UC was found to have non-occlusive chronic DVT within the left superficial femoral vein. Mild and moderate valvular incompetence was evenly distributed between the 3 groups. No patients met criteria for either acute DVT or severe venous incompetence. CONCLUSION: In patients with IBD, neither valvular incompetence nor chronic venous obstruction are over-represented compared to patients with IBS or normal volunteers. In this prospective assessment of venous physiology by duplex ultrasound, we were not able to confirm prior reports that IBD is a major risk factor for VTE.     

Current surgical approaches to venous hypertension and valvular reflux

Venous hypertension in the lower extremity with and without ankle ulceration can be attributed to venous outflow obstruction, venous valve incompetence with massive reflux. Compression stocking and pneumatic pump cannot provide a long-term cure of this advance stage of venous pathology and ulcer recurrence is to be expected. Definitive treatment requires the following sequential order: (1) correction of potential underlying coagulopathy (deficiency in Protein C, Protein S, anthrombin III), (2) correction of venous outflow obstruction in the pop-fem-iliac or inferior vena cava with venous bypass (balloon angioplasty of venous stenosis has disappointing long-term results because fibrocollagen is resistant to dilation), (3) correction of valve incompetence in the following order of preference: valvuloplasty, vein transposition, and valve transplantation, (4) perforator ligation and saphenous vein stripping, (5) compression stocking and pneumatic pump to enhance venous return and reduce superficial venous congestion. In nonpostphlebitic venopathy, compression stocking + pneumatic boot pump can function as a substitute for perforator ligation + saphenous vein stripping. There is high incidence of incompetence in transplated valve (53%) that can be restored with open valvuloplasty.Presented at the 36th Annual World Congress, International College of Angiology, New York, New York, July 1994     

Late results after venous valve repair

Seventeen patients (18 extremities) with primary deep venous insufficiency underwent femoral vein valve repair. Prior to the valvuloplasty the superficial and perforator systems were treated surgically. Dynamic venous pressure measurement and Doppler examination were done for late objective assessment of the valve repair. At early follow-up the reconstructed valves were competent, and all patients showed symptomatical improvement. Significant improvement in pressure reduction and recovery time was observed at postoperative venous pressure measurements. Good or excellent long-term results were obtained in 67% of the extremities after two to five years. Late recurrence of symptoms and incompetence of the reconstructed valve occurred in five extremities. Valve repair may offer good long-term results, but further studies are required to assess the appropriate place of this procedure in the treatment of primary deep venous insufficiency.     

Improvement of capillary permeability in patients with venous hypertension after treatment with TTFCA

The VSC (vacuum suction chamber) device, a new system to evaluate local capillary permeability, was used with laser Doppler flowmetry to study variations of permeability and of the microcirculation in 10 normal subjects; in 22 patients with moderate, superficial venous hypertension; and in 12 patients with postphlebitic limbs and severe venous hypertension. All these patients had distal (ankle and foot edema) in the evening. After a first assessment these subjects were studied again after two weeks without treatment and after two weeks' treatment with total triterpenic fraction of centella asiatica (TTFCA), tablets, 60 mg, tid. The VSC produces a wheal on the skin of the perimalleolar region that disappears (in average) in less than sixty minutes in normal subjects. The disappearance time (DT) is greater in conditions of increased capillary filtration and permeability. The three groups of subjects (normal and those with superficial and severe venous hypertension) had significantly different, increasing disappearance time of the wheals at the first observation. There were no significant changes after two weeks' observation, but after 2 weeks' treatment with TTFCA, there was a significant decrease of DT both in limbs with superficial and with deep venous incompetence. The improvement (decrease) of the abnormally increased capillary permeability was associated with a significant improvement of the microcirculation and symptoms (studied by an analogue scale line). In conclusion this study showed a combined improvement of the microcirculation and capillary permeability after treatment with TTFCA and the possibility of using the VSC to evaluate the effects of drugs (or other treatment) on local capillary permeability in patients with venous hypertension.     

老年退变型下肢深静脉瓣膜功能不全171例临床分析

目的　探讨 171例老年退变型下肢深静脉瓣膜功能不全 (DDVI)的临床表现及多普勒超声诊断。　方法　对 171例DDVI的临床和多普勒超声表现进行研究 ,将该组病例与非老年原发性深静脉瓣膜功能不全 (DVI)病例进行比较。　 结果　DDVI最常见的表现是小腿部水肿 ,占 79 9% (2 35条腿 ) ,DVI组最常见表现是浅静脉曲张 ,占 87 1% (2 76条腿 )。DDVI组平均静脉管径显著大于DVI组 ,P <0 0 1;DDVI组发生返流瓣膜组合是以多条大静脉同时出现为主 ,而DVI组则以单根为主。　 结论 　DDVI与一般DVI相比有特殊表现 ,多普勒超声检查能对其快速、安全、准确的诊断。     

Treatment of venous thrombosis associated with Behcet’s disease: immunosuppressive therapy alone versus immunosuppressive therapy plus anticoagulation

The aim of this study was to compare the efficacy of immunosuppressive therapy alone with that of combination therapy involving immunosuppressants and anticoagulation for the treatment of venous thrombosis in Behcet’s disease (BD). A retrospective analysis was made of 37 patients with venous thrombosis in BD. BD patients with venous thrombosis were divided into three groups: one group (N = 16) received immunosuppressive therapy alone, another group (N = 17) received immunosuppressant and anticoagulation combination therapy, and the third group (N = 4) received anticoagulation therapy only. Clinical and laboratory parameters and the recurrence of venous thrombosis were assessed. Venous thrombosis in BD appeared to have a more diffuse pattern than idiopathic type and a predilection for lower limbs. The most commonly involved sites were the superficial and common femoral veins. Recurrence of venous thrombosis occurred in two cases in the immunosuppressant group (12.5%), one case in the combination therapy group (5.9%), and three cases in the anticoagulant group (75%). No significant difference was found between recurrence in the immunosuppressant and combination therapy groups. Acute phase reactants were elevated in all six patients at the time of venous thrombosis recurrence. Our study suggests that immunosuppressive therapy is essential and that anticoagulation therapy might not be required for the treatment of deep venous thrombosis associated with BD.