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.     

Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution

PURPOSE: Radiofrequency ablation (RFA) of the greater saphenous vein (GSV; "closure") is a relatively new option for treatment of venous reflux. However, our initial enthusiasm for this minimally invasive technique has been tempered by our preliminary experience with its potentially lethal complication, deep venous thrombosis (DVT). METHODS: Seventy-three lower extremities were treated in 66 patients with GSV reflux, between April 2003 and February 2004. There were 48 (73%) female patients and 18 (27%) male patients, with ages ranging from 26 to 88 years (mean, 62 +/- 14 years). RFA was combined with stab avulsion of varicosities in 55 (75%) patients and subfascial ligation of perforator veins in 6 (8%) patients. An ATL HDI 5000 scanner with linear 7-4 MHz probe and the SonoCT feature was used for GSV mapping and procedure guidance in all procedures. GSV diameter determined the size of the RFA catheter used. Veins less than 8 mm in diameter were treated with a 6F catheter (n = 54); an 8F catheter was used for veins greater than 8 mm in diameter (n = 19). The GSV was cannulated at the knee level. The tip of the catheter was positioned within 1 cm of the origin of the inferior epigastric vein (first GSV tributary). All procedures were carried out according to manufacturer guidelines. RESULTS: All patients underwent venous duplex ultrasound scanning 2 to 30 days (mean, 10 +/- 6 days) after the procedure. The duplex scans documented occlusion of the GSV in 70 limbs (96%). In addition, DVT was found in 12 limbs (16%). Eleven patients (92%) had an extension of the occlusive clot filling the treated proximal GSV segment, with a floating tail beyond the patent inferior epigastric vein into the common femoral vein. Another patient developed acute occlusive clots in the calf muscle (gastrocnemius) veins. Eight patients were readmitted and received anticoagulation therapy. Four patients were treated with enoxaparin on an ambulatory basis. None of these patients had pulmonary embolism. Initially 3 patients with floating common femoral vein clots underwent inferior vena cava filter placement. Of the 19 limbs treated with the 8F RFA catheter, GSV clot extension developed in 5 (26%), compared with 7 of 54 (13%) limbs treated with the 6F RFA catheter (P =.3). No difference was found between the occurrence of DVT in patients who underwent the combined procedure (RFA and varicose vein excision) compared with patients who underwent GSV RFA alone (P =.7). No statistically significant differences were found in age or gender of patients with or without postoperative DVT (P = NS). CONCLUSION: Patients who underwent combined GSV RFA and varicose vein excision did not demonstrate a higher occurrence of postoperative DVT compared with patients who underwent RFA alone. Early postoperative duplex scans are essential, and should be mandatory in all patients undergoing RFA of the GSV.     

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.     

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 impact of isolated lesser saphenous vein system incompetence on clinical signs and symptoms of chronic venous disease

PURPOSE: The purpose of this study was to determine the patterns of isolated lesser saphenous vein (LSV) system incompetence and correlate the distribution and extent of such reflux with symptoms and signs of chronic venous disease (CVD). METHODS: During a 3-year period, 2254 limbs in 1682 patients with signs and symptoms of CVD were evaluated with color flow duplex scanning. Extremities with isolated reflux in the LSV system were selected for this study. Limbs with perforating venous reflux connected to this system only were also included. Limbs that had marked reflux in the greater saphenous or deep vein, that had a documented history of deep venous thrombosis, and that previously underwent surgery or sclerotherapy were excluded. The clinical severity of the limbs was graded with the CEAP classification system. RESULTS: There were 226 limbs in 200 patients with reflux in the LSV system; 61% were female patients with a mean age of 49 years (range, 18-82 years). There were 174 patients (87%) with unilateral and 26 with bilateral disease, and 41% of the limbs belonged in CVD class 2, 26% in class 3, 12% in class 4, 3.5% in class 5, and 3% in class 6. Classes 0 and 1 were present in 14.5% of the limbs. Symptoms were present in 139 limbs (61.5%). Some degree of ache or burning sensation was the most frequent symptom (41%), followed by itching (32%), heaviness (29%), cramps (24%), and restless limbs (18%). Reflux in the main trunk of the LSV was the most prevalent (177 limbs [78%]), followed by the saphenopopliteal junction (146 limbs [64.6%]), the vein of Giacomini (39 limbs [17%]) and the gastrocnemial vein (23 limbs [10%]). Reflux involving both the saphenopopliteal junction and the LSV was seen in 50% of limbs, but almost any other combination of reflux was present, which indicated the complexity of this system. Perforator vein incompetence was detected in 56 limbs (25%). We found 83 perforator veins, resulting in a mean of 1.5 veins per limb. Both the number of incompetent perforator veins and the extent of superficial reflux correlated with clinical severity. Four main types of termination of the LSV were identified with at least nine variations. The LSV was duplicated for at least half of its length in five limbs (2.2%). Nonsaphenous reflux was detected in seven limbs (3.1%). Superficial vein thrombosis in the LSV system was found in eight limbs (3.5%), and in the gastrocnemial vein it was found in four (1.8%). CONCLUSIONS: Isolated LSV system incompetence can cause the entire range of signs and symptoms of CVD. Clinical deterioration is associated with a longer extent of reflux and perforator incompetence. Classes 2 to 4 are the most frequent clinical presentations, whereas classes 5 and 6 are uncommon. The complex anatomy of this system and the great variation in the patterns of reflux warrant the use of color flow duplex scanning before planning treatment.     

How often is deep venous reflux eliminated after saphenous vein ablation?

BACKGROUND AND PURPOSE: Deep venous reflux resolution after great saphenous vein surgery has been reported, but the studies evaluated mainly patients with deep segmental reflux. We prospectively analyzed the effects of greater saphenous vein ablation on coexisting primary deep axial venous reflux compared with segmental venous reflux.Patients and methods Between February 1997 and June 2001, patients with primary deep venous reflux scheduled for greater saphenous vein surgery were included in the study. Limbs of patients with a history of deep venous thrombosis, thrombophlebitis, trauma, and orthopedic or venous surgery were excluded. After surgery, duplex scanning was repeated and patients were examined for persistent deep venous reflux. RESULTS: Thirty-three patients (38 limbs) were followed up with duplex scanning. Follow-up ranged from 2 weeks to 38 months. Preoperative axial deep reflux was present in 17 extremities, and segmental reflux was present in 21. The total number of incompetent segments was 59. Overall reflux abolishment rate was similar in extremities with axial and segmental reflux (30% vs 36%; P >.05). When segments were analyzed individually, abolishment of superficial femoral vein reflux was observed more often in extremities with segmental reflux than those with axial reflux (odds ratio, 4). In the extremities where deep reflux was not abolished with greater saphenous vein ablation, degree of reflux did not change significantly (P >.1). Duplex scanning was performed more than once during follow-up in 9 patients. In 3 of these patients reflux resolved by the second follow-up evaluation, and in 2 reflux was decreased at the second and third follow-up evaluations. CONCLUSION: In patients with concomitant deep and superficial venous reflux, saphenous vein ablation results in resolution of deep reflux in about a third of patients. Superficial femoral vein reflux is seldom corrected in limbs with axial reflux compared with those limbs with segmental reflux. To appreciate the effects of greater saphenous vein ablation, longer follow-up may be needed.     

Correlation of duplex ultrasound scanning-derived valve closure time and clinical classification in patients with small saphenous vein reflux: Is lesser saphenous vein truly lesser?

OBJECTIVE: We recently identified small saphenous vein (SSV) reflux as a significant risk factor for ulcer recurrence in patients with severe chronic venous insufficiency (CVI) undergoing perforator vein ligation. In this study we examined the role of SSV reflux in patients across the spectrum of CVI. METHODS: From March 15, 1997, to December 24, 2002, clinical and duplex ultrasound (US) scanning data from all valve closure time studies performed in our vascular laboratory were prospectively recorded. Valve closure time in the deep and superficial leg veins was assessed with the rapid cuff deflation technique; reflux time greater than 0.5 seconds was considered abnormal. SSV reflux was correlated with the CEAP classification system and eventual surgical procedure. Data were analyzed with Pearson chi(2) analysis. RESULTS: We analyzed 722 limbs in 422 patients, 265 (63%) female patients and 157 (37%) male patients, with a mean age of 48 +/- 12.8 years (range, 16-85 years). In the entire cohort the cause was congenital (Ec) in 5 patients, primary (Ep) in 606 patients, and secondary (Es) in 112 patients. SSV reflux was present in 206 limbs (28.5%) evaluated. Among limbs with SSV reflux, Ec = 4 (2%), Ep = 162 (79%), and Es = 40 (19%). SSV reflux did not correlate with gender, side, or age. The prevalence of SSV reflux increases with increasing severity of clinical class: C1-C3, 25.8% versus C4-C6, 36.1% (P =.006). SSV reflux is highly associated with deep venous reflux, 35.2% of femoral vein reflux (P =.015), 35.8% of femoral vein plus popliteal vein reflux (P =.001), and 40.5% of isolated popliteal vein reflux (P <.001). Great saphenous vein (GSV) reflux was identified in 483 (67%) limbs studied with valve closure time, whereas SSV reflux was present in 206 (28%) limbs. In this cohort, 127 GSV or SSV surgical procedures were performed subsequent to valve closure time examination. Among these operations 107 (84%) were GSV procedures, and only 20 (16%) were SSV procedures. CONCLUSION: SSV reflux is most common in patients demonstrating severe sequelae of CVI, such as lipodermatosclerosis or ulceration. The increasing prevalence of SSV reflux in more severe clinical classes and the strong association of SSV reflux and deep venous reflux suggest that SSV may have a significant role in CVI. Our data further show that, in our institution, a GSV with reflux is more than twice as likely to be surgically corrected as an SSV with reflux. It is time for the SSV to assume greater importance in the treatment of lower extremity venous disease. Future improvements in surgical techniques for access and visualization of the SSV may facilitate this method.     

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

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

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.     

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.     

Pregnancy-induced changes in lower extremity superficial veins: an ultrasound scan study

OBJECTIVE: The purpose of this study was to follow changes in superficial veins of the lower extremities during pregnancy and the postpartum period in women with varicose veins. METHODS: This was a prospective study with the use of duplex scanning during the first and third trimesters of pregnancy and postpartum period. Competent veins were defined as veins with an absence of reflux, and incompetent veins were defined as veins with reflux. The diameter of the competent or incompetent greater saphenous vein (GSV) and lesser saphenous vein (LSV) was measured. The diameter of the largest varicose dilatations was measured in all three networks: GSV and its tributaries, LSV and its tributaries, and nonsaphenous varicose veins. RESULTS: Sixty-six women were studied prospectively (mean age, 32.2 +/- 4 years; 85 affected extremities). The diameter of competent and incompetent GSVs and competent LSVs increased between the first and third trimester (P <.001) and decreased between the third trimester and the postpartum period (P <.001). The diameter of the largest varicose dilatations of the GSV and its tributaries and nonsaphenous networks increased between the first and third trimester (P <.001) and decreased between the third trimester and the postpartum period (P <.001). No statistically significant variation of the diameter was demonstrated for any of these veins between the first trimester and the postpartum period. CONCLUSION: The diameters of competent and incompetent superficial veins increased during pregnancy and decreased during the postpartum period to return to their baseline values.     

下肢静脉曲张疾病腔内激光治疗并发症的防治

目的：探讨激光治疗下肢静脉曲张疾病的并发症原因及防治方法。方法：回顾性分析420例（525条肢体）下肢大隐静脉曲张患者的临床资料。其中单纯性大隐静脉曲张324例(422条肢体)，下肢深静脉瓣膜功能不全96例(103条肢体)。采用单纯激光治疗263条肢体，激光加小切口静脉团点状剥脱159条肢体，激光治疗联合股浅静脉戴戒术25条肢体和激光加小切口静脉团点状剥脱联合股浅静脉戴戒术78条肢体。 结果：有331条肢体（占63.1%）术后出现与激光治疗有关的并发症，其包括：皮下淤斑268条肢体（占51.1%）, 隐神经损伤198条（占37.7%），腿部皮下血栓性静脉炎33条（占6.3%），小腿轻度皮肤灼伤26条（占5.0%）。全组无切口感染发生，无术后深静脉血栓形成的病例。术后380例(90.5%)获随访3~40个月，单纯性大隐静脉曲张者术后有27条肢体复发（复发率6.4%），下肢深静脉瓣膜功能不全者术后有8条肢体复发（复发率7.8%）。结论：在应用激光治疗下肢静脉曲张疾病过程中应重视对其并发症的预防和治疗，以充分体现激光治疗安全和微创的特点。     

Most incompetent calf perforating veins are found in association with superficial venous reflux.

PURPOSE: The indications for surgical perforator interruption remain undefined. Previous work has demonstrated an association between clinical status and the number of incompetent perforating veins (IPVs). Other studies have demonstrated that correction of IPV physiology results from abolition of saphenous system reflux. The purpose of this study was to identify which, if any, patterns of venous reflux and obstruction are particularly associated with IPV. PATIENTS AND METHODS: Two hundred thirty patients and subjects (103 men, 127 women, 308 limbs) with varying grades of venous disease were examined both clinically and with duplex ultrasound scan. The odds ratios (ORs) for the presence of IPVs were calculated for different anatomical distributions of main-stem venous reflux and obstruction. The base group are those with no main-stem venous disease. RESULTS: There were no significant associations between the proportions of limbs demonstrating IPVs and patient age or sex. The ORs for the presence of IPVs in association with other venous disease are as follows (age/sex adjusted): long saphenous vein reflux, OR = 1.86, range = 1.32-2.63; short saphenous vein reflux, OR = 1.36, range = 1.02-1.82; deep system venous reflux, OR = 1.61, range = 1.2-2.15; superficial system reflux, OR = 3.17, range = 1.87-5.4; and deep system obstruction, OR = 1.09, range = 0.51-2.33. The ORs for combinations of venous disorders were calculated. Combinations of disease produced higher odds for the presence of IPVs than those above, the highest being long saphenous vein, short saphenous vein, and deep reflux combined, OR = 6.85 (95% CI, 2.97-15.83; P =.0001). CONCLUSIONS: Although the presence of IPVs is associated with venous ulceration, the highest ORs for the presence of IPVs were found in patients with superficial disease alone or in combination with deep reflux. Many of these may be corrected by saphenous surgery alone.     

Ambulatory venous pressure revisited

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

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.)     

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.     

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

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

Endovenous laser treatment combined with a surgical strategy for treatment of venous insufficiency in lower extremity: a report of 208 cases

BACKGROUND: We assessed the safety and efficacy of endovenous laser treatment (EVLT) of the saphenous vein combined with a surgical strategy for treatment of deep venous insufficiency in the lower extremity. METHODS: Two hundred thirty venous insufficiencies of the lower limbs in 208 consecutive patients (93 men and 115 women; mean age, 54.15 years) were treated with EVLT combined with surgical strategies. All patients were symptomatic. There were 84 limbs (36.5%) in C(2), 25 (10.9%) in C(3), 109 (47.7%) in C(4), 1 (0.4%) in C(5), and 9 (3.9%) in C(6) (CEAP), and Klippel-Trenaunay syndrome was present in 2 limbs. A total of 119 (51.7%) had perforator vein incompetence. Four therapeutic methods were included in this series according to symptoms, CEAP classification, and venous reflux. Simple EVLT was performed for 15 patients with only great saphenous vein (GSV) incompetence or Klippel-Trenaunay syndrome in 19 lower limbs. EVLT combined with high ligation of the GSV and open ligation of perforators was performed for 5 patients with GSV and perforator incompetence in 5 lower limbs. EVLT was combined with high ligation of the GSV for 76 patients with GSV incompetence in 94 lower limbs. EVLT was combined with external banding of the first femoral venous valve and high ligation of the GSV for 112 patients with primary deep venous insufficiency in 112 lower limbs. All patients were followed up on an outpatient basis for physical examinations and postoperative complaints, and duplex ultrasonography was performed 2 weeks, 6 months, and 1 year after operation. RESULTS: All patients tolerated the procedure well and returned to normal daily activities immediately, achieving a 100% immediate clinical success rate. Spot skin burn injuries occurred in 2 patients (1.0%). Paresthesia in the gaiter area was noted in 15 patients (7.2%). No postprocedural symptomatic deep venous thrombosis or pulmonary embolism occurred. Three patients had local recurrent varicose veins in the calf (1.4%) during a 2- to 27-month follow-up (mean, 6.12 months). Postoperative clinical classes were significantly improved between 2 weeks and 24 months (P = .0001 at 2 weeks and 3 to 18 months; P = .0055 at 24 months compared with before operation), especially in preoperative C(2) to C(3) stage patients, who achieved complete amelioration. CONCLUSIONS: EVLT is a novel minimally invasive treatment with advantages of safety, effectiveness, and simplicity, and it leaves no scars. Its indications can be expanded by combining EVLT with surgical strategies.     

Relationship of venous reflux to the site of venous valvular incompetence: implications for venous reconstructive surgery

To evaluate the relationship of the site of venous valvular incompetence to the severity of venous reflux, legs of 71 patients with suspected chronic venous insufficiency were evaluated with Doppler ultrasonography and photoplethysmography. A venous recovery time (VRT) of less than 20 seconds after calf muscle exercise was considered indicative of significant reflux. Average VRTs were brief in 15 legs with stasis changes (10 +/- 7 seconds), longer in 42 legs with edema (26 +/- 23 seconds), and normal in 64 asymptomatic legs (37 +/- 24 seconds) and 16 legs with pain (53 +/- 19 seconds). Average VRTs in limbs with incompetent saphenous veins were abnormal. In limbs with competent superficial veins, only those with incompetent distal deep veins (popliteal and posterior tibial) had abnormal VRTs (14 +/- 10 seconds). VRTs in limbs with no detectable valvular incompetence and in those with incompetence limited to the proximal deep veins (common and superficial femoral) were normal (47 +/- 23 and 42 +/- 27 seconds, respectively). When superficial veins were incompetent, an ankle tourniquet normalized VRTs in 63% of legs with proximal deep venous incompetence and in only 33% of legs with distal deep venous incompetence. It is concluded that venous reflux is largely determined by saphenous and distal deep valvular function and that competence of the proximal valves has little effect. Decreased venous reflux would not be expected after proximal valvular reconstruction.     

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

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