Severe Chronic Venous Insufficiency Treated by Foamed Sclerosant

Our objective was to chronicle our experience in using sclerosant foam to treat severe chronic venous insufficiency (CVI). Forty-four patients with 60 limbs severely affected by severe CVI were entered into the study. They had lipodermatosclerosis, CEAP 4 (seven limbs); atrophie blanche or scars of healed venous ulcerations, CEAP 5 (18 limbs); and frank, open venous ulcers, CEAP 6 (35 limbs). Patients and limbs were collected into three groups. In group I, all limbs were treated with compression without intervention. Group II consisted of crossover patients who failed compression treatment. Group III consisted of patients treated promptly with sclerosant foam therapy without a waiting period of compression. A standing Doppler duplex reflux examination was done in all cases. Compression was by Unna boot or long stretch elastic bandaging. Foam was generated from Polidocanol 1%, 2%, or 3% by the two-syringe technique and administered under ultrasound guidance. Posttreatment compression was used for 14 days. In addition to clinical and ultrasound evaluation at 2, 7, 14, and 30 days, venous severity scoring was noted at entry and discharge. In group I, 12 patients were discharged from care within 6 weeks of initiating compression. All eight of the class 6 limbs had healed. Group II consisted of four CEAP class 5 limbs and eight class 6 limbs that had failed to heal with compression. Five of eight venous ulcers healed within 2 weeks, two more healed by 4 weeks, and one required 6 weeks to heal. In group III, 7 of 11 venous ulcers healed within 2 weeks and four more within 4 weeks. Venous severity scores reflected the success of treatment, with the greatest change occurring in group III and the least in group I. Limbs treated with foam had a statistically better outcome than those without (p = 0.041). One patient failed foam sclerotherapy, another had pulmonary emboli 4 months after foam treatment, and a single medial gastrocnemius thrombus was discovered 24 hr after treatment. Treatment of severe CVI with compression and foam sclerotherapy causes more rapid resolution of the venous insufficiency complications and does so without an increase in morbidity.     

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.     

Duplex Ultrasound Outcomes Following Ultrasound-Guided Foam Sclerotherapy of Symptomatic Primary Great Saphenous Varicose Veins

ObjectivesTo describe duplex ultrasound (DUS) outcomes 12 months following ultrasound-guided foam sclerotherapy (UGFS) of primary great saphenous varicose veins (GSVV).MethodsA consecutive series of UK National Health Service patients underwent serial DUS examinations following UGFS with 3% sodium tetradecyl sulphate for symptomatic primary GSVV.Results344 treated legs (CEAP C_2/3 237, C₄ 72, C₅ 14, C₆ 21) belonging to 278 patients (103 male) of median age 57 (range 21–89) years were enrolled between November 2004 and May 2007. The median volume of foam used was 10 (range 2–16) ml. Above-knee (AK) and below-knee (BK) GSV reflux was present in 333 (96.8%) and 308 (89.5%) legs respectively prior to treatment. AK and BK-GSV reflux was completely eradicated by a single session of UGFS in 323 (97.0%) and 294 (95.5%) legs respectively; and by two sessions of UGFS in 329 (98.8%) and 304 (98.7%) legs respectively. In those legs where GSV reflux had been eradicated, recanalisation occurred in 18/286 (6.3%) AK and 23/259 (8.9%) BK-GSV segments after 12 months follow-up.ConclusionsA single session of UGFS can eradicate reflux in the AK and BK-GSV in over 95% of patients with symptomatic primary GSVV. Recanalisation at 12 months is superior to that reported after surgery and similar to that observed following other minimally invasive techniques.     

Innovative Treatments in Chronic Venous Insufficiency: Endovenous Laser Ablation of Perforating Veins: A Prospective Short-term Analysis of 58 Cases

ObjectiveTo evaluate the efficacy of endovenous laser ablation of incompetent perforating veins.Study designProspective cohort study.PatientsA total of 58 perforating veins in 33 limbs of 28 patients were treated between March 2008 and February 2009 in an outpatient clinic setting. The average age was 65 years (range 30–81 years); 64% female; CEAP clinical stage C4 (67%), C5 (17%) and C6 (16%) (Clinica, Etiology, Anatomy and Pathophysiology, CEAP).MethodsAll patients underwent a standardised clinical examination and duplex ultrasonography. Guided by duplex ultrasonography, the perforating veins were cannulated percutaneously and tumescent local anaesthesia was given. An 810-nm diode laser was used to deliver 14 W power. Mean total energy delivered was 187 (range 87–325) J. Three months post-treatment, all patients underwent a further duplex ultrasound examination, to determine the treatment outcome.ResultsOcclusion of the perforating veins was achieved after 3 months in 78% of the cases. In the CEAP C6 group, four of five ulcers had healed after 6 weeks. No serious complications, including deep venous thrombosis, were encountered.ConclusionsEndovenous laser therapy for treating incompetent perforating veins is a safe and technically feasible technique. The initial occlusion rate is acceptable.     

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.     

Successful iliac vein and inferior vena cava stenting ameliorates venous claudication and improves venous outflow, calf muscle pump function, and clinical status in post-thrombotic syndrome

OBJECTIVES: Stent therapy has been proposed as an effective treatment of chronic iliofemoral (I-F) and inferior vena cava (IVC) thrombosis. The purpose of this study was to determine the effects of technically successful stenting in consecutive patients with advanced CVD (CEAP3-6 +/- venous claudication) for chronic obliteration of the I-F (+/-IVC) trunks, on the venous hemodynamics of the limb, the walking capacity, and the clinical status of CVD. These patients had previously failed to improve with conservative treatment entailing compression and/or wound care for at least 12 months. METHODS: The presence of venous claudication was assessed by > or =3 independent examiners. The CEAP clinical classification was used to determine the severity of CVD. Outflow obstruction [Outflow Fraction at 1- and 4-second (OF1 and OF4) in %], venous reflux [Venous Filling Index (VFI) in mL/100 mL/s], calf muscle pump function [Ejection Fraction (EF) in %] and hypertension [Residual Venous Fraction (RVF) in %], were examined before and after successful venous stenting in 16 patients (23 limbs), 6 females, 10 males, median age 42 years; range, 31-77 yearas, left/right limbs 14/9, using strain gauge plethysmography; 7/16 of these had thrombosis extending to the IVC. Contralateral limbs to those stented without prior I-F +/- IVC thrombosis, nor infrainguinal clots on duplex, were used as control limbs (n = 9). Excluded were patients with stent occlusion or stenoses, peripheral arterial disease (ABI <1.0), symptomatic cardiac disease, unrelated causes of walking impairment, and malignancy. Preinterventional data (< or =30 days) were compared with those after endovascular therapy (8.4 months; interquartile range [IQR], 3-11.8 months). Nonparametric analysis was applied. RESULTS: Compared with the control group, limbs with I-F +/- IVC thrombosis before stenting had reduced venous outflow (OF4) and calf muscle pump function (EF), worse CEAP clinical class, and increased RVF (all, P < 0.05). At 8.4 months (IQR, 3-11.8 months) after successful I-F (+/-IVC) stenting, venous outflow (OF1, OF4) and calf muscle pump function (EF) had both improved (P < 0.001) and the RVF had decreased (P < 0.001), at the expense of venous reflux, which had increased further (increase of median VFI by 24%; P = 0.002); the CEAP status had also improved (P < 0.05) from a median class C3 (range, C3-C6; IQR, C3-C5) [distribution, C6: 6; C4: 4; C3: 13] before intervention to C2 (range, C2-C6; IQR, C2-C4.5) [distribution, C6: 1; C5: 5; C4: 4; C2: 13] after intervention. At this follow up (8.4 months median), venous outflow (OF1, OF4), calf muscle pump function (EF), and RVF of the stented limbs did not differ significantly from those of the control; significantly worse (P < 0.025) were the amount of venous reflux (VFI), and the CEAP clinical class, despite the improvement with stenting. Incapacitating venous claudication noted in 62.5% (10 of 16, 95% CI, 35.8%-89.1%) of patients (15 of 23 limbs; 65.2%, 95% CI, 44.2%-86.3%) before stenting was eliminated in all after stenting (P < 0.001). CONCLUSIONS: Successful I-F (+/-IVC) stenting in limbs with venous outflow obstruction and complicated CVD (C3-C6) ameliorates venous claudication, normalizes outflow, and enhances calf muscle pump function, compounded by a significant clinical improvement of CVD. The significant increase in the amount of venous reflux of the stented limbs indicates that elastic or inelastic compression support of the successfully stented limbs would be pivotal in preventing disease progression.     

Long-term Results after Transfemoral Venous Thrombectomy for Iliofemoral Deep Venous Thrombosis

ObjectiveIn patients presenting with extensive venous thrombosis affecting the pelvic veins, transfemoral venous thrombectomy has been suggested as an effective treatment in selected patients. We present our experience of this technique as well as its long-term results.Patients and methodsBetween January 1998 and January 2008, a total of 83 patients underwent transfemoral venous thrombectomy in our Department of Vascular Surgery. In 22 cases, this was combined with angioplasty and stenting of an iliac vein stenosis. Isolated intra-operative thrombolysis was performed in eight cases to treat deep venous thrombosis (DVT) affecting veins distal to the common femoral vein. All patients suffered from a DVT involving the pelvic veins. A DVT involving all venous segments from the pelvis to the calf was present in 63% of cases. Patients were followed up at 3 months, 6 months and yearly thereafter by clinical and duplex ultrasound examination.ResultsIn all patients, the procedure was successful in achieving re-canalisation of the pelvic veins at the end of the operation. Perioperatively, there was no mortality and there was no case of clinically detected pulmonary embolism. Life-table analysis showed that, after a mean duration of 60 months following treatment, ～75% of the treated venous segments remained patent. Moderate post-thrombotic syndrome (PTS; clinical severity, etiology, anatomy and pathophysiology (CEAP) C2–C4) was present in 20% of cases; severe PTS (CEAP C5 and C6) did not occur in any of the treated patients.ConclusionsIt is safe and effective to treat extensive iliofemoral DVT using transfemoral venous thrombectomy and this prevents the development of severe PTS in the long term. The procedure is only feasible in a subset of patients with DVT, depending on the extent and the age of the thrombosis.     

Mid-term recurrence rate of incompetent perforating veins after combined superficial vein surgery and subfascial endoscopic perforating vein surgery

BACKGROUND: This study investigated the mid-term (mean, 3.7 years) clinical results and the results of duplex Doppler sonographic examinations of subfascial endoscopic perforating vein surgery (SEPS) in patients with mild to severe chronic venous insufficiency (clinical class 2-6) and assessed the factors associated with the recurrence of insufficient perforating veins (IPVs). METHODS: Eighty patients with mild to severe chronic venous insufficiency undergoing SEPS were evaluated, and duplex findings, as well as clinical severity and disability scores before and after the operation, were compared. Patients with prior deep vein thrombosis (<6 months) or prior SEPS were excluded from this study. RESULTS: There were 27 men and 53 women with a median age of 59.8 years (range, 34.3-80.0 years). The distribution of clinical classes (CEAP) was as follows: class 2, 13.1% (12 limbs); class 3, 22.8% (21 limbs); class 4, 19.6% (18 limbs); class 5, 21.7% (20 limbs); and class 6, 22.8% (21 limbs). The etiology of venous insufficiency was primary valvular incompetence in 83 limbs (90.2%) and secondary disease in 9 limbs (9.8%). Concomitant superficial vein surgery was performed in 89 limbs (95.7%). Twenty (95%) leg ulcers healed spontaneously within 12 weeks after operation, whereas one patient required additional split-thickness skin grafting. Eighteen patients had previous surgery of the great and/or short saphenous vein before SEPS. During a mean follow-up of 3.7 years, recurrence of 22 IPVs was observed in 20 (21.7%) of 92 limbs, and recurrent leg ulcers were observed in 2 (9.5%) of 21 limbs. We performed univariate and multivariate analyses to predict factors influencing the recurrence of IPVs (recurrent superficial varicosis, secondary disease, active or healed leg ulcer [C5/6], compression treatment, and previous operation). On multivariate analysis, previous surgery (P = .014) was identified as the only significant factor for the recurrence of IPVs. CONCLUSIONS: SEPS is a safe and highly effective treatment for IPVs. Within a median follow-up period of 3.7 years, only 2 of 21 venous ulcers recurred, both in patients with secondary disease. Nevertheless, we observed recurrence of IPVs in 21.7% of the operated limbs. On multivariate analysis, patients who had undergone previous surgery were found to have a significantly higher rate of recurrence.     

Study on the efficacy of surgery of the superficial venous system and of compression therapy at early stages of chronic venous disease for the prevention of chronic venous ulceration

The mainstay of treatment of chronic venous ulceration (CVU), as also suggested by current treatment guidelines for chronic venous disease (CVD), is represented by surgery and compression therapy for which there is strong evidence of their role in clinically relevant improvement in wound healing and also in the reduction of CVU recurrence, but no information is available as to whether or not these treatments provide effective protection from the onset of CVU. In our study, we have followed, for a median time of 13 years, a total of 3947 patients with CVD at classes C2–C3 of CEAP classification, treated with our treatment protocol (surgery and compression therapy) in order to track the natural history of these patients with regards to CVU development. We identified four groups of patients: 2354 patients (59·64%) (Group A) fully adherent to protocols; 848 patients (21·48%) (Group B) fully adherent to surgery and non‐compliant to compression therapy; 432 patients (10·95%) (Group C) fully adherent to compression therapy and non‐compliant to surgery; and 313 patients (7·93%) (Group D) non‐compliant to either treatments. Regardless of compliance to treatments, the ulcer development rates were very similar between groups (range: 3·23–4.79%), with no statistical significance (P = 0·1522). Currents treatments used in the early stages of CVD appear to have no effects to progression to CVU. Additional longitudinal studies are required to confirm these findings.     

The relationship between the number, competence, and diameter of medial calf perforating veins and the clinical status in healthy subjects and patients with lower-limb venous disease

PURPOSE: The role of medial calf perforating veins in the pathogenesis of the skin changes of chronic venous insufficiency (CVI) remains controversial. This study examined the relationship between abnormal medial calf perforating vein structure and function and the clinical severity of CVI. METHODS: Duplex ultrasound was used as a means of determining the number, flow characteristics, and diameter of medial calf perforating veins, and the presence of deep and superficial main stem reflux or occlusion in 50 limbs with no clinical or duplex evidence of venous disease (clinical, etiological, anatomical, and pathological grade [CEAP] 0), 95 limbs with varicose veins only (CEAP 2/3), 58 limbs affected by lipodermatosclerosis but not ulcer (CEAP 4), and 108 limbs affected by healed or open venous ulcer (CEAP 5/6). RESULTS: The proportion of limbs in which any perforating veins and incompetent perforating veins (IPVs) were demonstrated increased significantly with deteriorating clinical status (CEAP 0, 88% and 6%; CEAP 2/3, 95% and 52%; CEAP 4, 98% and 83%; and CEAP 5/6, 98% and 90%, respectively). The total number of perforators, the total number of IPVs, and the median diameters of perforators increased with deteriorating grade (CEAP 0 median diameter, 2 mm [interquartile range, 1 to 3 mm]; CEAP 2/3 median diameter, 3 mm [interquartile range, 2 to 4 mm]; CEAP 4 median diameter, 4 mm [interquartile range, 3 to 5 mm]; and CEAP 5/6 median diameter, 4 mm [interquartile range, 3 to 5 mm]). CONCLUSION: The deteriorating CEAP grade of CVI is associated with an increase in the number and diameter of medial calf perforating veins, particularly those permitting bidirectional flow.     

腔镜筋膜下交通静脉离断术治疗下肢慢性静脉功能不全

目的:探讨腔镜筋膜下交通支静脉离断术在治疗下肢慢性静脉功能不全中的作用。方法:选取CEAP分级C4级以上的患者22例(共27条肢体)行腔镜深筋膜下交通静脉离断术,并联合施行大隐静脉及曲张浅静脉剥脱术。结果:22例术后症状和浅静脉曲张消失,无切口感染坏死、皮下气肿及筋膜腔血肿等并发症。足靴区色素沉着及硬化明显改善,6例足靴区活动性溃疡在术后2周内愈合。随访1~12个月无静脉曲张及溃疡复发。结论:腔镜深筋膜下交通静脉离断术具有交通支静脉离断彻底、损伤小、恢复快、复发率低、并发症少等优点,可作为治疗CEAP分级Ap、PR的CVI患者的重要手段。     

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.     

Chronic venous disease treated by ultrasound guided foam sclerotherapy.

AIM: To report the outcome of a series of patients with chronic venous disease due to incompetence of saphenous trunks managed by ultrasound guided foam sclerotherapy (UFS). PATIENTS AND METHODS: A group of 808 patients comprise this series. CEAP clinical class for limbs was C1: 15%, C2: 81%, C3: 0.5%, C4: 2%, C5: 0.2%, C6: 0.4%. UFS using 1% polidocanol (107 limbs), 1% sodium tetradecyl (102 limbs), 3% sodium tetradecyl (900 limbs) was employed to treat incompetent saphenous trunks. In patients with unilateral varices 1 treatment was required in 43% of patients and 2 treatments in 48% of patients to obliterate incompetent saphenous trunks and varices. For bilateral varices 2 treatments were required in 40% of patients and 3 treatments in 46% of cases. The clinical outcome and patency of treated veins on duplex ultrasonography was assessed at a mean follow-up interval of 11 months. RESULTS: A total of 459 limbs were available for assessment at a follow-up interval of 6 months or greater. The CEAP clinical stage was C0:182 limbs, C1: 241, C2: 22, C3: 0, C4: 11, C5: 2, C6:1. The GSV had remained obliterated in 88% of limbs and the SSV in 82% of limbs. Recurrent venous incompetence following previous surgery was as effectively treated by UFS as primary incompetence. CONCLUSIONS: This technique is useful in the management of chronic venous disease as an alternative to surgery.     

Clinical Presentation and Patterns of Venous Reflux in Thai Patients with Chronic Venous Insufficiency (CVI)

ObjectiveTo study the extent of chronic venous insufficiency (CVI) in Thai patients by assessing venous clinical severity scores (VCSSs), venous disability scores (VDSs) and prevalence of lower limb venous reflux in a cohort of patients attending a vascular surgery clinic.DesignProspective comparative cohort study.MaterialAll patients presenting with CVI (Clinical, Etiology, Anatomy and Pathophysiology (CEAP) C4–6) in our vascular surgery clinic between October 2006 and December 2008 were enrolled and compared with the same number of control patients.MethodA standardised interview was conducted to document each patient’s history of venous disease, VCSS and VDS. Duplex ultrasonography of selected superficial and deep veins was performed.ResultsThere were 41 patients, mean age 58 years and a mean body mass index (BMI) of 26.7. Of 58 limbs, 35%, 19% and 47% were of CEAP clinical stages C4, C5 and C6, respectively. Previous deep vein thrombosis (DVT) was reported by 7% and major leg trauma by 9% of patients. The mean VCSS was 9.7 and mean VDS was 1.0. VDS 2 or 3 were found in 10% of patients. The VCSS 2 and 3 for pain, oedema and inflammation were found in 22%, 26% and 0% of C6 legs. The prevalence of combined superficial and deep vein reflux was 71%. The prevalence of isolated superficial and deep vein reflux were 8% and 17%, respectively. One patient had iliac vein occlusion. Compared with the control group, risk factors that were found to be significant were physical findings of varicose veins, history of leg trauma, standing posture and BMI.ConclusionsThai patients with CVI were relatively young. Visible varicose veins, pain, oedema and inflammation were uncommon and most patients could maintain their usual activities despite advanced venous disease. An association with obesity was not common. Despite a low prevalence of a history of previous DVT, the prevalence of deep vein reflux was high and commonly combined with superficial venous reflux.     

基于CEAP分级的下肢慢性静脉功能不全的综合诊治分析

目的通过CEAP分级探讨下肢慢性静脉功能不全的规范化诊治。方法对我院收治120例下肢慢性静脉功能不全患者按照CEAP分级,并根据患者的临床表现和彩超、下肢静脉造影等检查结果,主要依据临床(C)分级进行压迫治疗、药物治疗、手术治疗等联合的综合治疗措施。结果120例患者(135条患肢)按CEAP分级治疗后,随访局部复发率为18.52%(25/135),临床治疗效果良好。结论CEAP分级阐述了下肢静脉疾病的发展过程,避免了治疗的盲目性,使临床治疗有据可依,从而有助于下肢静脉疾病的规范化诊断和治疗。     

Photoplethysmographic Venous Refilling Times Following Ultrasound Guided Foam Sclerotherapy for Symptomatic Superficial Venous Reflux: Relationship with Clinical Outcomes

IntroductionDigital photoplethysmography (PPG) provides an inexpensive, reproducible, quantitative, non-invasive assessment of lower limb venous function.AimTo examine the relationship between venous refilling time (VRT) and severity of venous disease, and also between changes in VRT and symptomatic improvement after ultrasound guided foam sclerotherapy (UGFS) for symptomatic superficial venous reflux (SVR).MethodsPrior to and 6 months after UGFS, 246 patients (317 limbs) completed a symptom questionnaire, underwent duplex ultrasonography and clinical assessment, and VRT measurement by digital PPG. Health related quality of life (HRQL) questionnaires were also completed.ResultsMedian VRT improved from 11 to 31 s (P < 0.0005, Wilcoxon Signed Ranks). Abnormal VRT (<20 s) correlated well with the presence of SVR on duplex (sensitivity 75%, specificity 94%). Pre-treatment there was a significant relationship between reducing VRT and increasing CEAP clinical grade (P < 0.0005, χ²), extent of SVR on duplex (P < 0.0005) and a non-significant relationship with overall increasing symptom severity (P = 0.097). Relief of all symptoms was more likely when there was normalisation of VRT after treatment (80% vs. 65%, P < 0.0005, χ²). Pre-treatment VRT correlated with both generic physical (r = 0.428, P = 0.002) and disease-specific (r = ?0.413, P = 0.003, Spearman's rank) HRQL.ConclusionsUGFS for SVR improves VRT measured by digital PPG and that improvement correlates with symptom relief.     

Symptoms of chronic venous disease and association with systemic inflammatory markers

PURPOSE: We recorded symptoms reported by patients with chronic venous disease (CVD) of the leg and correlated these with systemic inflammatory markers. METHODS: This was an observational study in a cohort of 132 adult patients with CVD attending the vascular clinic of a teaching hospital. Patients were excluded in whom recent surgery, illness, or concomitant medication may have influenced measurements of systemic inflammatory mediators. Patients with CEAP clinical stages C(2) to C(5) only were considered for inclusion in the study. CEAP clinical stage was established for each patient, and duplex ultrasound scanning was used to assess extent of venous disease in the lower limbs. Blood was taken from a foot vein, and the following inflammatory mediators were measured with enzyme-linked immunosorbent assay: von Willebrand factor, intercellular adhesion molecule 1, vascular cell adhesion molecule 1, soluble (s)E-selectin, sP-selectin, L-selectin, VEGF, and cytokines interleukin (IL)-1 alpha, IL-1 beta, IL-6, and tumor necrosis factor-alpha. Symptoms were recorded by patients using a visual analog scale (VAS) for the symptoms of pain, cramps, heaviness, paresthesia, and feeling of swelling. RESULTS: The greatest VAS symptom scores were observed in the less severe disease stages: C(2) median pain score, 2.8 units (interquartile range [IQR], 0.1-5); C(3), 4.5 (IQR, 3.4-5.5), C(4), 0.5 (IQR, 0-3.0); C(5), 0 (IQR, 0-4). Symptom scores were similar in patients with primary and recurrent venous disease after previous surgery and in patients with superficial venous reflux and deep venous reflux. No correlation was found between the measurements of inflammatory mediators and the symptoms assessed with the VAS. CONCLUSION: We found no correlation between symptoms reported by patients and the internationally agreed clinical stages of venous disease of C(2) to C(5). Neither was there any correlation between levels of inflammatory mediators and patient symptoms. Symptoms reported by patients with CVD cannot be explained by anatomic distribution of venous disease in the lower limb veins or by the systemic inflammatory response in venous disease.     

Residual venous reflux after superficial venous surgery does not predict ulcer recurrence.

OBJECTIVE: The aim of this study was to investigate the importance of venous reflux in ulcer recurrence following saphenous surgery. METHODS: Ulcerated legs (CEAP 5 and 6) with saphenous reflux were treated with superficial venous surgery plus compression as part of a clinical trial. Patients unfit for general anaesthesia (GA) underwent limited surgery under local anaesthesia (LA). Reflux in superficial and deep segments and venous refill times (VRTs) were assessed before surgery and 3-12 months post-operatively using duplex and digital photoplethysmography respectively. RESULTS: Of 185 patients treated with surgery, 15 failed to heal and 26 did not have a follow-up duplex. Within 3 years, 25 of the remaining 144 patients (17%) developed ulcer recurrence. Using a Cox regression model, the presence of residual venous reflux and change in reflux pattern were not found to be risk factors for ulcer recurrence (p=ns). LA was used in 4/25 patients who recurred compared to 28/119 who did not (p=0.60; Chi-square test). For legs with recurrence, median VRT before surgery was 10.5s (range 5-29) compared to 11s (range 6-36) after surgery (p=0.097, Wilcoxon Signed Rank test). However, in legs without recurrence, median VRT increased from 10s (range 3-48) to 15s (range 4-48) after surgery (p<0.001). CONCLUSION: Residual reflux following saphenous surgery is not the most important predictor of venous ulcer recurrence. Poor venous function as demonstrated by VRT may be a better predictor of recurrence in these patients.     

Role of endovenous laser treatment in the management of chronic venous insufficiency

Endovenous laser therapy (EVLT) is a recognized option in the treatment of uncomplicated varicose veins. This uncontrolled case series evaluates its effectiveness in the management of chronic venous insufficiency. Patients with a history of active or healed ulcers were selected for EVLT. The procedure was carried out in an outpatient setting over a period of 12 months. Assessment was carried out for evidence of ulcer healing and recurrence, long saphenous vein occlusion, and patient satisfaction at 3, 12, and 22 months. Results are expressed as means with range. EVLT was used to treat 23 limbs in 20 patients with a median age of 59 years (range 32-76) including 12 females and eight males. All patients had evidence of chronic venous insufficiency, graded at C5 or greater on the CEAP classification (C5 16, C6 7). Patients with long saphenous vein insufficiency were included, whereas those with either deep or combined deep and superficial venous incompetence were excluded. The cumulative 3-, 12-, and 22-month healing rates were 87% (20/23), 100% (23/23), and 95% (21/22), respectively. The only patient having a recurrence of ulcers at 22 months' follow-up (CEAP 6) had mid-calf perforator incompetence with recanalized long saphenous vein. Duplex scan demonstrated long saphenous vein occlusion in 100% (23/23), 96% (22/23), and 91% (20/22) at 3, 12, and 22 months, respectively. In all, 84% (16/19) of patients were satisfied with the results of treatment without any major procedure-related complication. These results demonstrate that EVLT, carried out in an outpatient setting, is effective in the treatment and prevention of chronic venous ulcers, with good patient satisfaction and no major complication.     

Relationship of plasma vascular endothelial growth factor to CEAP clinical stage and symptoms in patients with chronic venous disease.

OBJECTIVE: Skin damage caused by chronic venous disease (CVD) is associated with severe microangiopathic changes in the skin. The aim was to determine whether patients in various CEAP clinical stages of CVD have elevated plasma levels of VEGF compared to controls and whether this correlates with the symptoms. METHODS: One hundred and eight patients with CVD attending the vascular clinic were included and assigned to the appropriate CEAP clinical stage. Thirty healthy control subjects were also included. Patients and controls were studied after resting supine for 10 min. Blood samples were taken from a dorsal foot vein. Assay of VEGF was performed with an enzyme-linked immunosorbent assay. Volunteers' symptoms were recorded using a visual analogue scale (VAS) for heaviness, cramps, paraesthesiae and swelling. RESULTS: Plasma levels of VEGF were: control (n30) median VEGF 56 pg/ml (inter-quartile range IQR 38-85), CEAP C2 (varicose veins) 86 (39-133), C5 (healed ulcer) 88 (67-135). Median difference: control vs. C5 33 (95% confidence interval (CI) 8-61). Median differences were calculated using the Wilcoxon method. VEGF level in patients with VAS swelling score=0:54 pg/ml (IQR 31-104). VEGF level in patients with VAS swelling score >0:85 pg/ml (IQR 40-147). Difference between medians: 20 ng/ml, 95% CI for the median difference: (5-44). No differences were observed for symptoms of heaviness, cramps or paraesthesiae. CONCLUSION: There was a trend towards raised VEGF in all stages of CVD, but this only reached statistical significance in those with healed ulceration. The symptom of swelling was associated with raised VEGF levels; however, the symptoms of heaviness, cramps, and paraesthesiae were not associated with raised VEGF levels.