Number and anatomical distribution of incompetent thigh perforating veins

Liquid Crystal Thermography and Duplex in the Preoperative Marking of Varicose Veins

Objective:

To determine the role of liquid crystal thermography (LCT) in preoperative marking of varicose veins and incompetent perforating veins.

Design:

Single patient group study comparing techniques.

Setting:

Teaching hospital vascular laboratory.

Patients:

Two hundred patients (265 legs) referred to St Mary's Hospital Vascular Laboratory for preoperative varicose vein marking.

Methods:

Patients were studied using LCT and duplex ultrasonography to identify calf perforating veins.

Results:

In part I of the study LCT identified 47 ‘areas at risk’, 42 of which were demonstrated to contain incompetent perforating veins on duplex examination (positive predictive value 89%). Thirty-eight of these 42 patients were explored at operation and 36 (95%) were confirmed as incompetent. The remaining two perforating veins could not be located. In part II of the study LCT identified 327 ‘areas at risk’, 299 of which were demonstrated to contain incompetent perforating veins on duplex examination (positive predictive value 91%).

Conclusion:

LCT is useful in the identification of incompetent perforating veins, it is easy to perform, less time consuming, cheaper and can replace duplex scanning.

Duplex Ultrasound Scanning for Chronic Venous Disease: Recurrent Varicose Veins in the Thigh after Surgery to the Long Saphenous Vein

Objective:

To use duplex ultrasound scanning to compare limbs with recurrent and primary varicose veins and to identify connections between deep veins and recurrences.

Setting:

A non-invasive vascular laboratory in Melbourne, Australia.

Patients:

A study of 779 limbs with recurrent varicose veins previously treated by ligation or stripping of the long saphenous vein and 1521 limbs with primary varicose veins.

Main outcome measures:

Connections between deep veins and recurrent varices, reflux in superficial and deep veins, and outward flow in perforators as demonstrated by duplex ultrasonography.

Results:

Recurrence was due to reflux in the long saphenous territory in 71.8%, short saphenous reflux alone in 14.7% or outward flow in calf perforators without saphenous reflux in 5.2%, while no source was detected in 8.3%. Limbs with recurrent veins in the long saphenous territory were compared with limbs with primary varicose veins; there was more frequent outward flow in thigh perforators (25.2% vs. 16.2%) but no difference for deep reflux (20.7% vs. 17.5%) or outward flow in calf perforators (56.8% vs. 53.1%). The source for recurrence in the long saphenous territory was from a single large connection in the groin in 46.3%, multiple smaller proximal connections in a further 46.3%, or thigh perforators in 7.4%. The destination was to an intact long saphenous vein in 33.7%, major tributaries in 28.7% or to other varices in 37.6%. Limbs known to have been treated by long saphenous ligation alone were compared with those known to be treated by long saphenous ligation and stripping; the source was more likely to be from a single large vein in the groin (60.3% vs. 39.9%) and the destination was more likely to be an intact long saphenous vein or major tributary (75.0% vs. 55.2%).

Conclusions:

Duplex ultrasound scanning detected the source of recurrent varicose veins in over 90% of patients and demonstrated whether there were single large or multiple smaller connections in the veins affected, and this helps to select the most appropriate treatment. Recurrence after stripping the long saphenous vein was more likely to be due to multiple small connections passing to scattered varices and this may allow more simple treatment by injection sclerotherapy rather than repeat surgery.

Stripping and ligation of the saphenous vein

Successful varicose vein surgery depends on accurate preoperative assessment and individualized treatment for various combinations of venous insufficiency. Noninvasive duplex scanning is currently the gold standard in varicose vein evaluation. Flush ligation and division of the great saphenous vein and its tributaries, inverted downward stripping to below the knee combined with stab avulsion of varicosities, have yielded excellent results for patients with great saphenous vein reflux. Additionally, identifying and correcting incompetent calf perforating veins is necessary to achieve a satisfactory outcome. Neovascularization at the saphenofemoral junction and varicose vein recurrence and their treatment remain unsolved and require further investigation.

Leg Perforator Vein Incompetence: Functional Anatomy

PURPOSE

To retrospectively determine the anatomic patterns of reflux of incompetent perforator veins (IPVs) at the sites of their highest prevalence in relation to the anatomic distribution of valvular incompetence in the veins of the calf and thigh, with emphasis on the deep system, across the clinical spectrum of chronic venous disease (CVD).

MATERIALS AND METHODS

This study was granted institutional ethics committee approval; the need for patient consent was waived. Five hundred five limbs in 359 consecutive subjects who were suspected of having CVD but did not have arterial disease, prior venous thrombosis (<1 year), venous or orthopedic surgery, or vascular malformations were clinically stratified for CVD according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) system and underwent venous hemodynamic investigation with duplex ultrasonography. One hundred thirty limbs were CEAP clinical classes C(0-1), 262 limbs were classes C(2-3), and 113 limbs were classes C(4-6). IPV reflux patterns and anatomic distribution of deep venous reflux in the lower limb were determined across the clinical classes of CVD. Statistical analysis was performed with Spearman rank correlation, chi(2), and Mann-Whitney testing.

RESULTS

Valvular incompetence in limbs with IPVs increased with CEAP clinical class (P < .01) in femoral, popliteal, posterior tibial, peroneal, gastrocnemial, and soleal veins; reflux was distributed evenly across these veins. Of 554 IPVs found, 377 (68.0%) occurred at four sites: middle third of medial calf (n = 165 [29.8%]), lower third of medial calf (n = 85 [15.3%]), middle third of medial thigh (n = 73 [13.2%]), and middle third of posterior calf (n = 54 [9.7%]). IPVs with superficial and deep reflux in adjoining veins, as compared with IPVs with superficial reflux alone, increased as clinical class increased from C(2) to C(6) (P < .02) at all four sites of highest IPV prevalence; determined in detail, reflux patterns of IPVs were linked to CEAP clinical class (P < .05) but not anatomic site (P > .2). Most IPVs in C(1-3) limbs had superficial reflux alone. IPVs with superficial reflux outnumbered IPVs with superficial and deep reflux even in C(4-6) limbs, where deep venous incompetence was most prevalent. Axial venous reflux (proximal-to-distal) changes (P > .4) were small in superficial and deep veins across the spectrum of CEAP clinical classes C(2-6).

CONCLUSION

Patterns of perforator reflux were linked to clinical severity of CVD in the CEAP classification and displayed an even distribution anatomically. IPVs with deep and superficial reflux in adjoining veins increased with CEAP clinical class, in line with valvular incompetence in the deep veins of the calf and thigh.

In situ hemodynamics of perforating veins in chronic venous insufficiency

PURPOSE

The prevalence of incompetent perforators increases linearly with the clinical severity of chronic venous insufficiency (CVI) and the presence of deep vein incompetence. Putative transmission of deep vein pressure to skin may cause dermal hypoxia and ulceration. Despite extensive prospective interest in the contribution of perforators toward CVI, their hemodynamic role remains controversial. The aim of this prospective study was to determine the in situ hemodynamic performance of incompetent perforating veins across the clinical spectrum of CVI, by means of duplex ultrasonography.

METHODS

A total of 265 perforating veins of 90 legs that had clinical signs and symptoms consistent with CVI in 67 patients referred consecutively to the blood flow laboratory were studied. The clinical distribution of the examined limbs was CEAP(0), 10 limbs; CEAP(1-2), 39 limbs; CEAP(3-4), 21 limbs; and CEAP(5-6), 20 limbs. With the use of gated-Doppler ultrasonography on real-time B-mode imaging, the flow velocity waveforms were obtained from the lumen of perforators on release of manual distal leg compression in the sitting position and analyzed for peak and mean velocities, time to peak velocity, volume flow, venous volume displaced outward, and flow pulsatility. The diameter and duration of outward flow (abnormal reflux > 0.5 seconds) were also measured.

RESULTS

Incompetent perforators had bigger diameters, higher peak and mean velocities and volume flow, longer time to peak velocity, and bigger venous volume displaced outward (VV(outward)) than competent perforators (all, P <.0001). The diameter of incompetent perforators did not change significantly with CEAP class (all, P >.1). Incompetent thigh and lower-third calf perforators had a significantly bigger diameter than perforators in the upper and middle calf combined (both, P <.05), in incompetent perforators: reflux duration was unaffected by CEAP class or site (P >.3); peak velocity was higher in those in CEAP(3-4) than those in CEAP(1-2) (P =.024); mean velocity in those in CEAP(3-6) during the first second of reflux was twice that of those in CEAP(1-2) (P <.0001); both higher volume flow and VV(outward) were found in the thigh perforators than those in the upper and middle calf thirds (P <.03); CEAP(3-6) volume flow and VV(outward), both in the first second, were twice that in those in CEAP(1-2) (P <.002); flow pulsatility in those in CEAP(5-6) was lower than in those in CEAP(1-2) (P =.014); in deep vein incompetence, higher peak velocity, volume flow, VV(outward), and diameter occurred than in its absence (P <.01). CEAP designation correlated significantly with mean velocity and flow pulsatility, both in the first second (r = 0.3, P <.01). The flow direction pattern in perforator incompetence was uniform across the CVI spectrum: inward on distal manual limb compression, and outward on its release; competent perforators had a smaller percentage of outward flow on limb compression (P <.01).

CONCLUSION

In addition to an increase in diameter, perforator incompetence is characterized by significantly higher mean and peak flow velocities, volume flow, and venous volume displaced outward, and a lower flow pulsatility. Differences in early reflux enable a better hemodynamic stratification of incompetent perforators in CVI classes. In the presence of deep reflux, incompetent perforators sustain further hemodynamic impairment. In situ hemodynamics enable quantification of the function of perforators and can be used in the identification of the clinically relevant perforators and the impact of surgery.

New insights into perforator vein incompetence

BACKGROUND

there has been much controversy on the role of perforator veins in the development of chronic venous disease (CVD). This study was designed to determine the duration and direction of flow of lower limb perforator veins (PVs) in relation to their location, diameter and competency status of superficial and deep veins, in healthy volunteers and patients with different grades of CVD.

PATIENTS AND METHODS

thirty limbs in 15 symptom-free volunteers and 103 limbs in 75 patients with signs and symptoms of CVD were examined with colour-flow duplex scanning. Superficial, perforator and deep veins were studied in the standing and sitting positions. Flow-velocity characteristics, the number and maximum PV diameter at the deep fascia and subfascially were determined. A PV was considered incompetent when the outward flow lasted >0.5 s.

RESULTS

581 PVs were found in the patients and 106 in the volunteers. 163 PVs (28%) were incompetent in the first group and none in the latter. The total number of PVs and the number of incompetent PVs per limb increased significantly with the severity of CVD. The mid-calf area had more competent and incompetent PVs in patients (p <0.01). Mean diameter of incompetent PVs in all the CVD classes was significantly larger than that of competent PVs. Competent PVs tended to be larger with increasing severity of CVD and they were significantly larger in the CVD classes 4 to 6 compared to controls (p <0.01). Subfascial PV diameter was markedly larger than that at the fascial level (p <0.001) regardless of the CVD class. A subfascial PV diameter of >3.9 mm (95% CI 3.4 to 4.4 mm) indicated incompetence. However, the reverse was not true, because about a third of incompetent PVs had a subfascial diameter of <3.9 mm. Both competent and incompetent PVs were smaller when located at the lower thigh, knee, ankle and anterior aspect of the calf than those found in the rest of the calf and mid-thigh (p =0. 03). Both inward and outward flow was found more often in patients than in controls (70/418 vs. 9/106, p =0.048). Most incompetent PVs had outward flow alone (126, 77%). PV incompetence was most frequently associated with reflux in superficial veins (120, 74% (p <0.0001), followed by reflux in both the superficial and deep veins (34, 21%) and reflux in the deep veins alone (9, 5%). The mean duration of outward flow was markedly longer in the presence of both superficial and deep vein reflux compared to superficial (p <0.001) or deep vein reflux alone (p <0.0001).

CONCLUSIONS

the number of incompetent PVs and the diameter of both competent and incompetent PV increases with the severity of CVD. Bidirectional PV flow is more common in patients than in normal volunteers, while 77% of the incompetent PVs have outward flow alone. PV incompetence is most often associated with reflux in the superficial veins, indicating that deep venous reflux is rarely the primary cause of PV insufficiency.

Recurrent varicose veins: patterns of reflux and clinical severity

Duplex scanning was used to determine patterns of recurrent varicose veins in 264 limbs and to relate these to clinical factors. All limbs had previously undergone sapheno-femoral ligation in the groin. A recurrent sapheno-femoral junction was present in 172 (65.2%). Incompetence was found in long or short saphenous veins in 232 limbs (87.9%), perforators in 176 (66.7%), and deep veins in 156 (59.1%). Residual long saphenous veins were present in 43.4% and 73.6% of limbs that were with and without stripped long saphenous veins, respectively. An incompetent thigh perforator was present in 14.0% and 15.3% of these two groups, respectively. Multiple sites of incompetence were observed in the majority (75.4%). In general, no particular reflux pattern in the groin was related to an increased incidence of ulceration. However, ulceration was more frequent in limbs with deep reflux to knee or below-knee levels. None of those with isolated reflux in the groin that was unrelated to the common femoral vein had ulceration. The pattern of reflux was unrelated to striping or non-striping of the long saphenous veins and the time since initial surgery. A history of deep vein thrombosis was invariably associated with some degree of deep reflux. A system of recurrent patterns in the groin is described for the purpose of surgical audit. In 15.1%, recurrence was attributed with some confidence to inadequate surgery. These results indicate that the pattern of recurrence is highly variable and often with multiple sites of incompetence. In a few instances, the pattern of recurrence was associated with specific clinical factors. A full work-up including duplex scanning is recommended.

A prospective randomized trial evaluating the haemodynamic role of incompetent calf perforating veins

AIM

This study was undertaken to determine the haemodynamic effect of incompetent calf perforating veins in patients with uncomplicated varicose veins and long saphenous incompetence.

METHODS

Thirty-eight limbs from 35 patients were studied. All patients had uncomplicated varicose veins with both long saphenous and calf perforator incompetence on duplex ultrasonography. Patients were randomized to have incompetent calf perforators ligated or left intact, in addition to saphenofemoral junction ligation, strip of long saphenous vein to knee and stab avulsion of any visible varicosities in the leg. Patients were assessed with air plethysmography pre-operatively and 3 months postoperatively.

RESULTS

Superficial venous surgery improved venous volume, venous filling index and ejection fraction in the patient cohort. No significant haemodynamic difference was demonstrated between the two groups of patients who were randomized.

CONCLUSIONS

At present, the results of this study do not support the use of routine perforator ligation during superficial surgery for uncomplicated varicose veins.

Treatment of primary varicose veins: an assessment of the combination of high saphenous ligation and sclerotherapy

This study was conducted to determine the optimal treatment for minimizing the recurrence of varicose veins, and to assess the value of the combined treatment of high saphenous ligation and sclerotherapy. A combined total of 967 limbs in 660 patients with primary varicose veins were treated. The treatments comprised: sclerotherapy alone in 81 limbs, high saphenous ligation alone in 3 limbs, a combination of sclerotherapy and high saphenous ligation in 843 limbs, and a combination of sclerotherapy and ligation of incompetent perforating veins in 10 limbs. Recurrent varicose veins appeared from 3 months after the initial treatment in 61 (6.3%) limbs. Saphenous-type recurrence, being the presence of saphenofemoral incompetence (SFI) and/or saphenopopliteal incompetence (SPI), was found in 20 limbs, and further treatment was given. Segmental-type recurrence, being superficial varices without SFI or SPI, was found in 41 limbs, all of which were treated with further sclerotherapy alone. To minimize the recurrence rate of varicose veins, the presence or absence of SFI, SPI, and incompetent perforating veins must be confirmed prior to the initial treatment. It was concluded that the combination of high saphenous ligation and sclerotherapy is effective for patients with SFI and/or SPI, whereas sclerotherapy alone is better for patients without SFI or SPI.

How successful is varicose vein surgery? A patient outcome study following varicose vein surgery using the SF-36 Health Assessment Questionnaire

OBJECTIVE

Assessment of outcome after varicose vein surgery.

DESIGN

Prospective study using the Health Assessment Questionnaire (SF36) which considers different aspects of overall health.

SETTING

University Hospital and Community.

MATERIALS

150 patients undergoing varicose vein surgery.

CHIEF OUTCOME MEASURES

SF36 questionnaires were sent pre-operatively and at 1 and 6 months post surgery.

MAIN RESULTS

Eighty-nine (59%) patients answered all three questionnaires. Pre-operatively their overall health was similar to that of the general population. The "cost" to the patient of the operation was demonstrated by an increased pain and reduced role function at 1 month post-operation (p < 0.01). By 6 months post-operation, when compared with preoperative values, all dimensions except social function and health perception were improved (p < 0.01). Overall symptoms improved (p < 0.01) by 1 month and were further improved at 6 months.

CONCLUSIONS

The general good health of varicose vein patients may justify the low priority given to their treatment, but the improvement in symptoms and general health that relatively simple surgery provides should ensure its continued provision as a health care service.

Anatomy of the superficial venous system

BACKGROUND

A number of informative and detailed scientific communications have been published in recent years on the functional anatomy of the lower extremity venous system.

OBJECTIVE

This paper is aimed at providing basic anatomic information for physicians interested in phlebology. It also highlights the new research areas and the changing concepts on the the pathophysiology of varicose veins.

METHODS

The material is concentrated on observations made during duplex scan examination of the venous drainage of normal and abnormal limbs.

RESULTS

The etiology and classification of varicose veins are discussed, followed by a description of the subcutaneous venous anatomy based upon ultrasound studies. The anatomy of venous reflux in different segments of the superficial venous system is examined in the light of recent duplex ultrasound findings.

CONCLUSION

The presentation and treatment of varicose veins may vary depending on the anatomical distribution of valvular incompetence.

Recurrent varicose veins. Part 1: Evaluation utilizing duplex venous imaging

There is the need to develop a universally accepted standard investigation for recurrent varicose veins. Duplex venous imaging offers a precise, non-invasive technique to make anatomic and hemodynamic diagnoses. A routine protocol of duplex imaging of recurrent varicose veins is described based on the known recurrent sources of reflux from deep to superficial veins. Results from this protocol indicate that incompetent perforating veins are the most common site of reflux from deep to superficial veins in patients with recurrent postsurgical varicose veins. Other important sites of reflux detected by this method are recurrent communications with the common femoral vein, the saphenopopliteal junction, and incompetent pelvic veins. Duplex imaging is recommended as a safe, non-invasive method of evaluating recurrent varicose veins.