A colour Doppler ultrasound study of venous reflux in patients with chronic leg ulcers.

OBJECTIVES: to evaluate the distribution of superficial and deep venous reflux in patients with chronic leg ulcers. MATERIALS: retrospective study of 186 patients with chronic leg ulcers (212 lower limbs). RESULTS: in 127 legs without arterial disease and a history of deep venous thrombosis (DVT), 62 (49%) had superficial, 45 (35%) had superficial and deep, and 14 (11%) had isolated deep venous reflux. In legs with a previous DVT, isolated deep venous reflux was more common (21/55, 38%) but superficial reflux, often in combination with deep reflux, still predominated (56%). CONCLUSIONS: a large part of the venous insufficiency causing venous leg ulcers is superficial and suitable for varicose vein surgery. In patients with chronic leg ulcers most reflux affects the superficial system and is potentially suitable for surgical correction.     

Evaluation of vascular and metabolic deficiency in patients with large leg ulcers.

A consecutive series of 50 patients with large leg ulcers (surface area > 100 cm2) were investigated for evidence of arterial, venous and nutritional problems. Arterial insufficiency was found in 34%, venous reflux in 50%. A group of eight patients had no arterial or venous problem but had serious deficiencies of vitamin C and zinc. Arterial bypass was performed successfully in 15 of the 17 patients with arterial disease. All patients had a mesh split-skin graft. The 25 with venous incompetence had compression bandaging; in these patients the ulcer had healed on discharge but 10 had recurrent ulceration within 6 months. The leg ulcers in patients with corrected arterial insufficiency healed significantly more rapidly than those with venous incompetence. The ulcers in those with nutritional deficiency healed promptly after skin grafting and correction of the deficiency. It is important to be aware of arterial insufficiency and nutritional deficiency in patients with leg ulcers, as such deficiencies may contribute to the non-healing of an apparently straightforward leg ulcer.     

Postthrombotic or non-postthrombotic severe venous insufficiency: impact of removal of superficial venous reflux with or without subcutaneous fasciotomy

BACKGROUND: Severe chronic venous insufficiency is often associated with therapy-resistant or recurrent venous leg ulcers, either as a result of deep vein thrombosis (DVT)- (postthrombotic syndrome [PTS]) or superficial venous insufficiency (SVI). Frequently present dermatoliposclerosis affects the skin as well as the subcutaneous and subfascial structures, which may impact tissue pressures and compromise skin perfusion. This study was undertaken to measure tissue pressures in PTS and SVI limbs and to evaluate the impact of removal of superficial venous reflux with or without concomitant subcutaneous fasciotomy. MATERIAL: In eight patients with recurrent, therapy-resistant venous leg ulcers, due to PTS (11 limbs, 12 ulcers) and 14 patients with severe SVI (14 limbs, 14 ulcers), subcutaneous fasciotomy was performed in addition to removal of superficial reflux. They were compared with eight patients with PTS (11 limbs, 11 ulcers) and 10 patients with SVI (13 limbs, 13 ulcers) who did not have fasciotomy in addition to removal of their superficial venous reflux. Intramuscular (i.m.) and subcutaneous (s.c.) tissue pressures and transcutaneous oxygen tension (TcPO(2)) were measured prior to, immediately after, and 3 months following the surgical intervention. Healing of ulcer (spontaneous or by skin grafting) at 3 months was also observed. RESULTS: There were no statistical differences between the groups regarding gender and age distribution or ulcer age at the time of surgery. All patients had in addition to surgery compression stockings class II (30 mm Hg). The i.m. tissue pressure was higher in patients with PTS compared with SVI patients, while s.c. tissue pressure and TcPO(2) did not differ between the groups. When fasciotomy was performed, i.m. and s.c. tissue pressures decreased and TcPO(2) increased significantly. Without fasciotomy, only s.c. tissue pressure decreased first at 3 months postoperatively. In the SVI-group, i.m tissue pressure was significantly decreased at 3 months in the group without fasciotomy. CONCLUSIONS: Patients with severe chronic venous insufficiency with therapy-resistant or recurrent ulcer disease due to deep and superficial insufficiency have higher i.m. tissue pressures than patients with only superficial venous reflux, even though both groups have higher i.m. and s.c. tissue pressures compared with normal values. Eradication of all superficial reflux lowers s.c. tissue pressure, while additional fasciotomy lowers both i.m. and s.c. tissue pressures and increases TcPO(2), which seems to promote ulcer healing.     

Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the North American subfascial endoscopic perforator surgery registry. The North American Study Group

PURPOSE: The safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery (SEPS) for the treatment of chronic venous insufficiency were established in a preliminary report. The long-term clinical outcome and the late complications after SEPS are as yet undetermined. METHODS: The North American Subfascial Endoscopic Perforator Surgery registry collected information on 148 SEPS procedures that were performed in 17 centers in the United States and Canada between August 1, 1993, and February 15, 1996. The data analysis in this study focused on mid-term outcome in 146 patients. RESULTS: One hundred forty-six patients (79 men and 67 women; mean age, 56 years; range, 27 to 87 years) underwent SEPS. One hundred and one patients (69%) had active ulcers (class 6), and 21 (14%) had healed ulcers (class 5). One hundred and three patients (71%) underwent concomitant venous procedures (stripping, 70; high ligation, 17; varicosity avulsion alone, 16). There were no deaths or pulmonary embolisms. One deep venous thrombosis occurred at 2 months. The follow-up periods averaged 24 months (range, 1 to 53 months). Cumulative ulcer healing at 1 year was 88% (median time to healing, 54 days). Concomitant ablation of superficial reflux and lack of deep venous obstruction predicted ulcer healing (P <.05). Clinical score improved from 8.93 to 3.98 at the last follow-up (P <. 0001). Cumulative ulcer recurrence at 1 year was 16% and at 2 years was 28% (standard error, < 10%). Post-thrombotic limbs had a higher 2-year cumulative recurrence rate (46%) than did those limbs with primary valvular incompetence (20%; P <.05). Twenty-eight of the 122 patients (23%) who had class 5 or class 6 ulcers before surgery had an active ulcer at the last follow-up examination. CONCLUSIONS: The interruption of perforators with ablation of superficial reflux is effective in decreasing the symptoms of chronic venous insufficiency and rapidly healing ulcers. Recurrence or new ulcer development, however, is still significant, particularly in post-thrombotic limbs. The reevaluation of the indications for SEPS is warranted because operations in patients without previous deep vein thrombosis are successful but operations in those patients with deep vein thrombosis are less successful. Operations on patients with deep vein occlusion have poor outcomes.     

Angioscopy-assisted valvuloplasty for primary deep venous valvular insufficiency

Primary deep venous valvular insufficiency causes reflux syndrome. Angioscopy permits the surgeon not only to ascertain that venous valves have not been destroyed but to perform external valvuloplasty under visual control with the valves under pressure. We have performed angioscopy-assisted venous valvuloplasty in three men (mean age 36 years; range 30 to 38 years) and one woman (age 58 years). All four patients had class 3 disease (SVS/ISCVS classification). Descending phlebograms showed grade 3 reflux in one patient and grade 4 reflux in three patients. In all patients angioscopy-assisted valvuloplasty of the superficial femoral vein was combined with wrapping with a segment of polytetrafluoroethylene prosthesis, stripping of incompetent superficial veins, and subfascial ligation of perforating veins. Mean follow-up was 12 months (range 6 to 17 months). In three patients ulcers healed and did not recur; in the remaining patient nearly complete healing was obtained after skin grafting. In all patients ambulatory venous blood pressure improved significantly and venous filling time returned to normal (> 15 seconds). At duplex ultrasonography and descending phlebography, no residual reflux was demonstrated. At final follow-up, all repaired valves were patent and competent. Our experience demonstrates that angioscopy-assisted venous valvuloplasty combines the accuracy of valvuloplasty by means of phlebotomy and the simplicity of external valvuloplasty and thus is preferred to either of these methods.     

Is the nihilistic approach to surgical reduction of superficial and perforator vein incompetence for venous ulcer justified?

OBJECTIVE: Twenty-five years ago, the senior author showed a 55% postoperative ulcer recurrence rate after open perforator ligation. Those data contributed to a nihilistic attitude toward incompetent perforating veins. Conversely, since the introduction of subfascial endoscopic perforator surgery (SEPS), we have undertaken ablation of superficial and perforator reflux as initial treatment in patients with ulcers (C6) or healed ulcers (C5). This report outlines our long-term results. METHODS: Between December 1994 and November 1999, SEPS was performed on 51 limbs in 45 patients with C5/C6 disease. Sixteen limbs underwent SEPS alone, and 35 had additional surgery on the greater saphenous vein (GSV), the lesser saphenous vein, or the tributary varicies. Data were collected according to the reporting standards in venous disease. Preoperative duplex scan of deep, superficial, and perforating veins was performed. Data were analyzed with Kaplan-Meier method, Mantel-Cox log-rank test, or t test. RESULTS: Of the 51 limbs that underwent SEPS, the GSV was stripped in 28. Twenty-nine were C6, and 22 were C5. Etiology was primary (Ep) in 25 limbs and secondary (Es) in 26 limbs. All limbs had duplex scan evidence of perforator incompetence (Ap), and deep insufficiency (A(D)) was seen in 39 cases (76%). Reflux predominated (P(R)). The clinical follow-up period was 0 to 82 months (median, 38 months). Venous disability scores improved from 9.8 before surgery to 4.2 at last follow-up (P <.05). Kaplan-Meier analysis showed 74% healing at 6 months. The presence of an ulcer more than 2 cm in diameter, secondary etiology, and SEPS without concomitant GSV stripping were associated (P <.05) with delayed healing. Among patients in whom ulcers healed or who were seen with healed ulcers, the 5-year ulcer recurrence rate was 13%. Lesser saphenous vein reflux was the only factor that correlated with increased ulcer recurrence. Deep system reflux as measured with duplex scan valve closure times did not correlate with the rate of ulcer healing or recurrence. CONCLUSION: Nihilism has no place in the management of venous disease in the 21st century. An aggressive approach to superficial and perforating vein reflux in this cohort of patients with C5 and C6 disease resulted in rapid ulcer healing and low 5-year recurrence rates. Prior saphenous vein stripping, large ulcers, and secondary etiology were associated with delayed healing. A less aggressive posture toward lesser saphenous vein reflux contributed to a higher recurrence rate in this subgroup of patients. These risk factors are useful in counseling patients as to their expected postoperative course; however, no combination of factors should a priori preclude surgical intervention in this group of patients.     

Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing

OBJECTIVE: The objective of this study was to determine the effectiveness of treatment of nonhealing heel ulcers and gangrene and to define those variables that are associated with success. METHODS: A multi-institutional review was undertaken at four university or university-affiliated hospitals of all patients with wounds of the heel and arterial insufficiency, which was defined as absent pedal pulses and a decreased ankle/brachial index (ABI). Risk factors, hemodynamic parameters, and arteriographic findings were statistically analyzed to determine their effect on wound healing. Life-table analysis was used to assess graft patency and wound healing. RESULTS: Ninety-one patients (57 men, 34 women) were treated for heel wounds that did not heal for 1 to 12 months (62% of nonhealing wounds, 3 months or longer). The mean preoperative ABI was 0.51, and 31% of wounds were infected. Of the patients, 55% had impaired renal function (Cr > 1.5), with 24% undergoing dialysis, 70% had diabetes, and 64% smoked cigarettes. Treatment was topical wound care for all patients and operative wound débridement in 50%. Infrainguinal bypass was performed for 81 patients, 4 had inflow procedures, 3 had superficial femoral artery percutaneous transluminal angioplasty, and 3 had primary below-knee amputation. Postoperatively, 85% of patients had in-line flow to the foot with at least a single patent vessel, 66% had a pedal pulse, and the mean ABI improved by 0.40, to 0.91. Follow-up ranged from 1 to 60 months (mean, 21 months), and 77 patients (85%) are currently alive. In 66 patients (73%), the wounds healed-all within 6 months (mean, 3 months). For 14 (16%) the wounds had not healed, and 11 patients (11%) underwent below-knee amputation. By life-table analysis, limb salvage was 86% at 3 years. During follow-up, 75 infrainguinal bypasses (91%) remained patent (3 secondarily) and 6 occluded, with primary assisted patency of 87% at 3 years. All wounds in patients with occluded grafts failed to heal. Variables found to be statistically significant in predicting healing included normal renal function (95% healed vs 55% nonhealed, P <.002), a palpable pedal pulse (85% healed vs 42%, P <.0015), a patent posterior tibial artery past the ankle (86% healed vs 57%, P <.02), and the number of patent tibial arteries after bypass to the ankle (P <.0001). Neither the ABI nor the presence of infection (defined as positive tissue cultures or the presence of osteomyelitis), diabetes, or other cardiovascular risk factors influenced the outcome. CONCLUSIONS: Complete wound healing of ischemic heel ulcers or gangrene may require up to 6 months, and short-term graft patency is of minimal benefit. Successful arterial reconstruction, especially a patent posterior tibial artery after bypass, is effective in treating most heel ulcers or gangrene. Patients with impaired renal function are at increased risk for failure of treatment, but their wounds may successfully heal and they should not be denied revascularization procedures.     

Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency.

OBJECTIVE: Although newer techniques to promote the healing of leg ulcers associated with chronic venous insufficiency are promising, improved healing rates and cost effectiveness are unproven. We prospectively followed a series of patients who underwent treatment with outpatient compression for venous stasis ulcers without adjuvant techniques to determine healing rates and costs of treatment. METHODS: Two hundred fifty-two patients with clinical or duplex scan evidence of chronic venous insufficiency and active leg ulcers underwent treatment with ambulatory compression techniques. The patients were prospectively followed with wound measurements at 1-week to 2-week intervals, and the factors that were associated with delayed healing were determined. RESULTS: Of all the ulcers, 57% were healed at 10 weeks of treatment and 75% were healed at 16 weeks. Ultimately, 96% of the ulcers healed, and only 1 major amputation was necessitated (0.4%). Initial ulcer size and moderate arterial insufficiency (ankle brachial index, 0.5 to 0.8; n = 34) were factors that were independently associated with delayed healing (P <.01). Patient age, ulcer duration before treatment, and morbid obesity did not significantly affect healing times. The cost of 10 weeks of outpatient treatment with compression techniques ranged from $1444 to $2711. CONCLUSION: The treatment of venous stasis ulcers with compression techniques results in reliable, cost-effective healing in most patients. Current adjuvant techniques may prove to be useful but are likely to be cost effective only in a minority of cases, particularly in patients with large initial ulcer size or arterial insufficiency.     

Reduction in deep vein reflux after concomitant subfascial endoscopic perforating vein surgery and superficial vein ablation in advanced primary chronic venous insufficiency

BACKGROUND: Subfascial endoscopic perforating vein surgery (SEPS) and superficial vein surgery (SVS) have been the recommended treatment for advanced chronic venous insufficiency (CVI), despite a high prevalence of deep vein reflux in these patients. The anatomic and hemodynamic results of these procedures, however, remain uncertain. It is hypothesized that concomitant SEPS and SVS would result in a reduction of deep vein reflux in patients with advanced primary CVI. We investigated the effect of concomitant SEPS and SVS on deep vein reflux as well as the associated hemodynamic and clinical changes after surgery in a cohort of patients with advanced primary CVI. METHODS: We prospectively evaluated 53 consecutive SEPSs with concomitant SVS procedures in 47 patients with advanced primary CVI. There were 25 men and 22 women with a mean age of 58 years at operation. Thirty-four procedures (64%) were performed for limbs with active venous ulcers (class 6), and the other 19 procedures were performed for 15 class 5 limbs, one class 4a limb, and three class 4b limbs, respectively. Duplex scan and air plethysmography were performed before operation, at 1 month, and at 1 year after operation. The patients were followed up regularly with clinical assessment, and the ulcer healing and recurrence rates were documented. RESULTS: The proportion of limbs with common femoral vein incompetence decreased from 68% to 28% at 1 month and to 32% at 1 year after operation. The proportion of limbs with deep vein incompetence at more than one site also decreased from 42% to 15% at 1 month and to 12% at 1 year after concomitant SEPS and SVS. Venous hemodynamics as measured by air plethysmography improved significantly after operation. The cumulative ulcer healing was 85% at 3 months and 97% at 6 months. With a mean follow-up of 31 +/- 16 months, all ulcers healed. Only three recurrent ulcers (6%) were detected during the follow-up period. CONCLUSION: Concomitant SEPS and SVS are effective in reducing deep vein reflux and results in hemodynamic and clinical improvements in patients with advanced primary CVI. Deep vein reconstruction procedures may not be necessary in these patients.     

Surgery of the superficial venous system in elderly patients

Chronic venous insufficiency, which traditionally has been attributed to failure of the deep venous system, may result from reflux in the superficial venous system. Chronic venous insufficiency is common in elderly patients, but surgical treatment is seldom offered to this patient population. We evaluated the results of superficial venous surgery for the treatment of severe chronic venous insufficiency in a cohort of elderly patients. The authors assessed patients aged 70 years or more with chronic venous insufficiency that had failed conventional conservative treatment. The superficial and deep venous systems were thoroughly investigated by duplex ultrasonography. Associated medical conditions were reevaluated and their treatment optimized. Twenty-eight patients (11 men, 17 women), aged between 70 and 89 years (mean 79), underwent superficial venous surgery. Open ulcers, active dermatitis and recurrent erysipelas were evident in 12, 9 and 7 patients, respectively. Limb swelling and severe pain were present in 25 (89%). The operations were performed under general or regional anesthesia with overnight hospitalization. Surgical treatment consisted of ligation of the points of reflux at the junctions of the superficial and deep systems, as defined by the duplex examination (21 saphenofemoral junctions, 5 saphenopopliteal junctions, 10 perforator veins), and stripping of the long saphenous vein to knee level (15 patients). Postoperative ambulatory treatment was continued until the wounds were completely closed. All ulcers healed completely within 8 weeks. No cardiac, respiratory, or renal complications were encountered. Wound infection at the groin occurred in 1 patient. Cellulitis of the calf area developed in 4 patients. Two ulcers recurred during follow-up of 1 to 5 years (mean 2.5). Surgery of the superficial venous system for treatment of severe chronic venous insufficiency is effective and can be achieved with minimal morbidity in selected elderly patients. The risk/benefit ratio for this procedure has been reduced sufficiently to ensure a major improvement in the quality of life of such patients.     

Treatment of leg ulcers with split skin grafts: early and late results.

Sixty patients (mean age 73.5 years) with 88 leg ulcers that had not responded to conservative treatment had split skin grafts applied at the Department of Plastic Surgery, Link?ping, Sweden. Of 51 venous leg ulcers 45 (88%) healed after a mean of 15 days (range 5-30); and 13 (62%) of the 21 arterial ulcers healed after a mean of 18 days (range 8-30). Additional skin grafting was done on nine of the venous and on three of the arterial ulcers. Twenty-two (49%) of the healed venous ulcers recurred after a mean of four months while only two (15%) of the healed arterial ulcers recurred after a mean of 10 months. At late follow up after a mean of four years 18 of the patients were dead and 10 had had the leg in question amputated. Of the 34 patients still alive who had not had amputations, 31 were investigated at open ward or interviewed by telephone and 23 patients were examined with colour duplex scan. Seven of these patients had open leg ulcers. At duplex scan six patients had no venous or arterial insufficiency that could cause a leg ulcer. Of 16 patients with venous insufficiency 10 patients had only an inadequate superficial system. The mean cost for treating one leg ulcer by skin grafting is estimated at SEK 89000 (US$11125). We conclude that leg ulcers often heal with skin grafting but that venous ulcers often recur. To reduce the recurrence rate we suggest a better preoperative aetiological evaluation and improved postoperative treatment with a compression bandage.     

Division of incompetent perforator veins and subfascial interposition of a polypropylene foil in post-thrombotic syndrome. Preliminary results

AIM: The safety, feasibility and early efficacy of subfascial endoscopic perforator surgery was gradually accepted for patients who had severe chronic venous insufficiency but, in the literature, the recurrence rate of ulceration is about 10-40%, especially in patients with previous deep vein thrombosis (DVT). METHODS: From October 1998 to February 2002, 205 patients with 280 inferior leg ulcers were followed; 115 had venous ulcers but only 20 patients had chronic ulcers with previous DVT; 4 patients were excluded and only 16 patients (9 female, 7 male, mean age 61 years) with 18 chronic ulcers were included. These patients underwent sub-aponeurotic interruption of perforating veins with blind technique in association with subfascial interposition of a hand-made polypropylene foil. Eight of these patients had persistent non-healing ulcers at the time of surgery and 10 had chronic recurrent ulceration healed at the time of the surgical procedure. All patients were assessed clinically and with duplex scanning. RESULTS: The follow-up was done clinically and with eco-Doppler from 6 to 38 months with a mean follow up period of 23.2 months. The healing rate was 100%. The 2-year life table incidence of ulcer recurrence was 0%. Hospital stay ranged from 1-2 days, early operative complications included extensive ecchymosis in 1 patient, oedema in 3 patients. CONCLUSION: The division of perforating veins, with the subfascial support of a polypropylene foil give promising results in the treatment of venous ulcers in post-thrombotic syndrome with low morbidity and short hospital stay.     

True long-term healing and recurrence of venous leg ulcers following SEPS combined with superficial venous surgery: a prospective study.

BACKGROUND: The role of perforator surgery remains unclear in the management of patients with leg ulcers. The aim of this study was to assess long-term healing and recurrence rates of leg ulcers following surgical intervention with combined Subfascial Endoscopic Perforator Surgery (SEPS) and superficial venous surgery. METHOD: Case series with prospective long-term follow-up of 90 consecutive patients operated on with open (CEAP C6) or healed (CEAP C5) venous ulcers in 97 legs. Popliteal vein reflux was present in 21 legs. All 97 legs were treated with SEPS and 87% had additional superficial venous surgery. Patients were follow-up for a median of 77 months (range 60-112 months) with a minimum of 5 years. RESULTS: 87% of all ulcerated legs healed. The three and five year recurrence rates were 8% and 18% respectively among survivors. In a multivariate Cox regression analysis previous vein surgery was the only factor significantly associated with recurrent ulceration (p=.004). CONCLUSION: SEPS combined with superficial venous surgery leads to healing with a low recurrence rate in patients with open and healed venous ulcers. Previous venous surgery was found to be a significant risk factor for ulcer recurrence. This result emphasizes the importance of assiduous technique for varicose vein surgery and suggests a continuing role for perforator surgery in leg ulcer patients.     

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.     

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.     

Subfascial endoscopic perforator vein surgery combined with saphenous vein ablation: results and critical analysis

OBJECTIVE: This study was undertaken to determine the results of subfascial endoscopic perforator vein surgery (SEPS) combined with ablation of superficial venous reflux. METHODS: Clinical data were retrospectively analyzed for 74 consecutive limbs (65 patients) in which this combination treatment was performed at a university medical center. Preoperatively, 58 lower extremities had an open venous ulcer (CEAP clinical class 6 [C(6)]) and 16 had healed ulceration (C(5)). Preoperative and postoperative ulcer care remained constant. Main outcomes measured included perioperative complications, ulcer healing, and ulcer recurrence. Clinical severity and disability scores were tabulated before and after surgery. Mean patient follow-up was 44 months. RESULTS: Greater saphenous vein (GSV) stripping and varicose vein excision accompanied SEPS in 57 limbs (77%), and SEPS was performed alone or with varicose vein excision in 17 limbs that had previously undergone GSV stripping. Postoperative complications occurred in 12 limbs (16%), all with C(6) disease (P =.04). Ulcer healing occurred in 91% (53 of 58) of limbs with C(6) disease at a mean of 2.9 months (range, 13 days-17 months). Multivariate analysis demonstrated that ulcer healing was negatively affected by previous limb trauma (P =.011). Ulceration recurred in 4 limbs (6%) at 7, 20, 21, and 30 months, respectively. This was associated with a history of limb trauma (P =.027) and preoperative ultrasound evidence of GSV reflux combined with deep venous obstruction (P(R,O); P =.043). Clinical severity and disability scores improved significantly after surgery (both, P <.0001). CONCLUSIONS: Most venous ulcers treated with SEPS with ablation of superficial venous reflux heal rapidly and remain healed during medium-term follow-up. Ulcer healing is adversely affected by a history of severe limb trauma, and ulcer recurrence is similarly affected by a history of limb trauma in addition to superficial venous reflux combined with deep venous obstructive disease. Overall, there was marked improvement of postoperative clinical severity and disability scores compared with those obtained before surgery.     

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.     

Patterns of venous insufficiency after an acute deep vein thrombosis

BACKGROUND: The purpose of this study was to investigate patterns of venous insufficiency during a 12-month period after an acute deep vein thrombosis. STUDY DESIGN: Seventy limbs in 67 patients with an acute deep vein thrombosis (DVT) involving 147 anatomic segments were evaluated with duplex scanning at 1 month, 3 months, 6 months, and 1 year. Venous segments were examined whether they were occluded, partially recanalized, or totally recanalized, and the development of venous reflux was evaluated. RESULTS: The segments investigated were the common femoral vein (38 segments), femoral vein (33 segments), popliteal vein (36 segments), and calf veins (40 segments). There were 35 limbs with isolated DVT and the remaining 35 had multisegment DVT. At 1 year, thrombi had fully resolved in 76% of the segments, 20% remained partially recanalized, and 5% were occluded. The venous occlusion was most predominant in the femoral vein (21%) at 1 year. On the contrary, rapid recanalization was obtained in calf veins than in proximal veins at each examination (p < 0.01). Deep vein insufficiency was detected as early as 1 month after development of DVT, and the reflux was most predominant in popliteal veins (56%), followed by femoral veins (18%). No reflux was found in calf veins. Multisegment DVTs had a significantly higher incidence of deep vein insufficiency than single segment DVTs at 1 year. Development of superficial venous insufficiency was found in 5 limbs (7%) and perforating vein insufficiency in 5 (7%). CONCLUSIONS: Lower extremity venous segments showed different proportions of occlusion, partial recanalization, and total recanalization. Calf veins showed more rapid recanalization than proximal veins. Venous reflux was noted as early as 1 month. The limbs involving multisegment DVTs on initial examination had a higher incidence of deep vein insufficiency and could require much longer followup studies.     

Surgical treatment for venous ulcers: is it worthwhile?

We have reviewed the results of treatment of 159 consecutive limbs presenting with a clinical diagnosis of venous ulcer in 140 patients (70 male, aged 28-90 years, median 66 years). Of the patients, 61% were referred because of severe pain and 53% of the ulcers had been present > 2 years. Patients were evaluated clinically and by Doppler, with selective use of venography, photoplethysmography, arteriography and latterly duplex scanning. Seventy-one limbs had surgery to the superficial veins, 18 limbs had arterial reconstruction, and 10 limbs had skin grafting alone. There was one operative death after arterial reconstruction but none after venous surgery. Patients were followed up for 1-5 years (median 3 years). Of those who had been treated surgically, healing was achieved in 88%, and ulcers healed in 52% of those treated non-operatively. In all, 18% of the ulcers recurred in each group. These results show a favourable association between appropriate venous and arterial surgery and the healing of venous ulcers, with relief of pain. They support a policy of thorough evaluation and appropriate surgical treatment in these patients.     

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??Reconstructive surgery for deep vein reflux for left iliac vein stenosis complicated with severe deep venous insufficiency: An analysis of 73 cases MA Jie*??MA Tao. *Department of Vascular Surgery, No. 210 Hospital of Chinese People's Liberation Army, Dalian116012, China
Corresponding author??MA Jie??E-mail??majie541019@sina.com
Abstract Objective To report the clinical outcomes and mid-term results of deep vein valve reconstruction combined with superficial vein surgery in treating deep venous insufficiency (DVI) complicated with left iliac vein stenosis (LIVS). Methods From January 2007 to June 2014??73 cases of DVI complicated with LIVS (male 14??female 59??mean age 49.7) were diagnosed via ascending venography. Deep venous valve reconstruction surgery were performed. Pre-and postoperative Doppler ultrasound??dynamic venography were conducted. Hemodynamic??thrombosisstatus and venous clinical severity score (VCSS) were recorded and compared. Results Among 73 cases, venography results showed 60 cases (82.1%) had stenosis rate between 50.6??to 58.7??and 13 cases (17.9%) had stenosis rate between 60.1?? to 65.6??. All the cases had Kistner Class III-IV venous reflux. Postoperative popliteal vein reflux quantity [??165.61±10.25??mL ] was significant lower than preoperative popliteal vein reflux quantity [??812.63±57.42??mL] (t=12.17??P<0.001). VCSS reduced from preoperative ??7.98±1.35?? to postoperative ??1.47±0.68?? (t=54.62??P<0.001). All the cases were followed-up for 58 months. No postoperative thrombosis was observed. Limb pain and swelling were relieved??ulcers were healed in 96.2% of the cases??ulcer recurrent rate was 3.8%. Conclusion The deep vein valve reconstruction surgery at the popliteal vein??combined with great saphenous vein??small saphenous vein and perforator vein surgery in treating DVI complicated with LIVS (>50%??65%) is safe and effective??providing satisfactory long-term results.