The effect of long saphenous vein stripping on deep venous reflux

Clinical outcomes after treatment of incompetent saphenous vein combined with segmental popliteal vein reflux

OBJECTIVE

This study aims to evaluate whether differences exist in the quality of life changes and complication rates after treatment of incompetent saphenous vein (ISV) based on the presence of segmental popliteal vein reflux (SPVR).

METHODS

Patients who underwent treatment for ISV from July 2016 to July 2021 were included and divided into two groups: patients without deep venous reflux (DVR) and patients with SPVR. Patients with axial DVR, history of deep vein thrombosis (DVT), history of orthopedic surgery, previous venous treatment, and no postoperative follow-up were excluded from the study. Duplex ultrasonography was performed preoperatively and at 6 and 12 months postoperatively.

RESULTS

The study included 233 patients (398 limbs), and 50 (64 limbs) had SPVR. Differences were not observed in gender, age, body mass index (BMI), distribution of clinical class according to Clinical-Etiology-Anatomy-Physiology (CEAP) classification, laterality, treatment method, and preoperative Venous Clinical Severity Score (VCSS) or Aberdeen Varicose Vein Questionnaire (AVVQ) scores between the two groups with SPVR or without DVR. Furthermore, the VCSS and AVVQ scores at 6 and 12 months postoperatively were improved in both groups but without significant differences. A significant difference was not observed in the rate of postoperative complications between the groups based on the presence of SPVR (1.8% vs. 1.6%: p = 1.00). The SPVR improvement rate after ISV treatment was 25% (16/64), and patient-reported outcomes in patients combined with SPVR improved independent of treatment modality, saphenous vein treatment section, and postoperative SPVR improvement.

CONCLUSIONS

Complication rates and clinical outcomes after ISV treatment did not differ in the presence of SPVR. In patients combined with SPVR, after ISV treatment, quality of life improved regardless of treatment modality, saphenous vein treatment section, and postoperative SPVR improvement.

Characteristics of venous leg ulcer patients at a tertiary wound care center

OBJECTIVE

The objective of this study was to assess patient, wound, care, and reflux characteristics of venous leg ulcers (VLUs) to update and improve knowledge of disease etiology, identify barriers to healing, and improve treatment.

METHODS

Patients diagnosed with VLUs treated at the Stanford Advanced Wound Care Center between 2018 and 2019 were identified from the Healogics iHeal database. We identified 327 VLU entries, of which 133 were patients who had multiple or recurring wounds. An additional 27 patients were labeled as misdiagnosis, resulting in a final patient sample of 167. Patient demographics, wound, care, and ultrasound data for these patients were extracted from the Stanford electronic medical records regarding characteristics. The initial data analysis suggested possible differences in VLU characteristics depending on patient age and body mass index (BMI), which was then further analyzed.

RESULTS

Of the 167 VLU patients assessed, 53.9% were male and 46.1% were female. The mean age was 74.7 years, and the average BMI was 30.2 kg/m2, including 41.1% of patients with a BMI over 30 kg/m2. Approximately 50% of wounds were presented in multiples, had cellulitis, or were recurring, and 39.5% were caused by trauma. Most common venous reflux patterns on duplex ultrasound examination were below-knee great saphenous vein reflux and calf perforator reflux, which was identified in 37.7% and 29.3% of the patients, respectively. Axial great saphenous vein reflux was detected in 14.4% of patients. When looking at the patient sample under 60 years of age, 67.7% were male, 61.3% presented with venous skin changes, and 51.6% had diabetes. In the patients older than 60, only 51.9% were male, 37.6% presented with venous skin changes, and 31.6% had diabetes. BMI was greater in the patients under age 60, with an average of 39.2 kg/m2, compared with 28.2 kg/m2 in those above 60. Of the patients with a BMI ≥30 kg/m2, 64.3% had multiple wounds, 61.4% had recurring wounds, and 56.5% had venous skin changes. In contrast, in patients with BMI <30 kg/m2, 47.4% had multiple wounds, 39.2% had recurring wounds, and 32.0% had venous skin changes.

CONCLUSIONS

VLU pathology appears to differ depending on patient demographics and characteristics. Different drivers may influence disease cause, progression, and prognosis, making a standard approach to VLUs difficult. Our findings suggest that identifying different subtypes of VLUs and adapting an algorithm of care with a personalized treatment may help optimize management of these patients.

Chronic venous insufficiency: Part 2 Diagnosis and treatment

Chronic venous insufficiency (CVI) is a common medical condition that results from venous hypertension of the extremities, leading to significant morbidity. The diagnosis of CVI is quite straightforward from patient history and obvious clinical manifestations. In the recent past, availability of various invasive and non-invasive modalities have assisted in evaluation of such cases. Although compression therapy is the mainstay of management, newer surgical and other interventional techniques are now being considered for patients who do not respond to conventional medical management. This review article will outline a diagnostic approach in cases of CVI and discuss the management principles encompassing conservative, pharmacological, and interventional options.

A systematic review of the treatment of residual below the knee venous reflux after endovenous thermal ablation of the great saphenous vein

BACKGROUND

Great saphenous vein (GSV) antireflux procedures have evolved during the past few decades to reduce elevated venous pressure. Untreated reflux in the below knee (BK) GSV (BK-GSV) can lead to persistent venous hypertension and deterioration of the venous circulation. The purpose of the present systematic review was to study the influence of BK-GSV intervention on venous disease progression.

METHODS

A search was conducted, adhering to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The PubMed and Embase databases were searched and cross-referenced. Studies were included if they had met the inclusion criterion of BK-GSV disease as a primary or secondary outcome. Two of the authors independently determined the eligibility and extracted the relevant data. RevMan, version 5.3 (Cochrane Training, London, UK), and SPSS (IBM Corp, Armonk, NY) were used for statistical computation.

RESULTS

Fifteen studies that had assessed BK-GSV reflux recurrence after ablative intervention were included in our analysis. Of the 15 studies, 6 had assessed patients after above knee (AK) high ligation and stripping (HLS), 7 after AK endovenous laser ablation (AK-EVLA), and 2 after AK- and BK-EVLA (AK+BK EVLA). In total, 525 limbs had undergone HLS, 696 AK-EVLA, and 147 AK+BK EVLA. AK+BK EVLA was associated with significantly lower odds of BK-GSV reflux recurrence compared with AK-EVLA only (odds ratio [OR], 0.1857; 95% confidence interval [CI], 0.076-0.4734; P < .0001). Although the odds of recurrent BK-GSV reflux appeared to be greater for patients who had undergone AK-HLS compared with AK+BK HLS, the difference was not statistically significant (OR, 0.62; CI, 0.27-1.43; P = .69). Finally, no statistically significant difference was observed in BK-GSV reflux recurrence between patients receiving AK-EVLA and those receiving AK-HLS (OR, 0.85; 95% CI, 0.52-1.39; P = .31).

CONCLUSIONS

Axial hydrostatic reflux from the groin to ankle is best controlled with AK+BK-GSV ablation. However, GSV ablation can result in saphenous nerve injury. For C4 to C6 disease, more aggressive treatment of the AK+BK-GSV is justified if the duplex ultrasound findings demonstrate groin to ankle reflux. Thermal ablation of the BK-GSV has a lower incidence of saphenous nerve injury than does BK saphenous stripping. More randomized controlled trials are needed to answer questions involving disease recurrence and the best techniques to mitigate these recurrences.

Influence of Superficial Venous Ablation on Deep Venous Dilation and Reflux in Patients With Saphenous Varicose Veins

BACKGROUND

To investigate the influence of superficial venous ablation on deep venous dilation and reflux in patients with saphenous varicose veins, and to elucidate the association between superficial venous reflux and deep venous morphology and hemodynamics.

METHODS

The data of 154 patients with 223 limbs, who underwent endovenous radiofrequency ablation (RFA) of the great saphenous vein for primary varicose veins between September 2014 and March 2016 in Eniwa Midorino Clinic, were retrospectively analyzed. Overall venous hemodynamics of the leg, including functional venous volume (VV) and venous filling index (VFI), was assessed using air-plethysmography. Saphenous and deep vein reflux and diameter were evaluated with duplex scanning.

RESULTS

Hemodynamic and morphologic changes were evaluated before and 1 month after RFA. The VV and VFI were significantly decreased in postoperative values than in preoperative values (P < .001). Limbs with deep venous reflux significantly decreased postoperatively than preoperatively (P < .001). There were significant differences in the diameter of the common femoral vein (CFV) and popliteal vein (PV) between the preoperative and postoperative values (P < .001). There were strong to moderate correlations between the VV and the diameter of the CFV or PV (CFV, r = 0.47, P < .001; PV, r = 0.35, P < .001), while there were moderate to weak correlations between the VFI and the diameter of the CFV or PV (CFV, r = 0.23, P < .001; PV, r = 0.33, P <.001).

CONCLUSIONS

Superficial venous ablation significantly reduced deep venous dilation and reflux in patients with saphenous varicose veins. Significant correlations existed between the VV or VFI, which reflected superficial venous reflux, and the diameter of the deep veins. These findings reveal that volume overload due to superficial venous reflux is associated with deep venous morphology and hemodynamics.

Different management options for primary varicose veins in females: A prospective study

Background

The aim of this study was to evaluate the long-term follow-up results of different management modalities in treating primary uncomplicated lower limb female varicosities.

Methods

A prospective study took place within a 3-year period from June 2010 until May 2012. Patients were divided into 3 groups: group I (n = 35) included those who underwent open surgical treatment. Group II (n = 25) included those who subjected to ultrasound-guided foam sclerotherapy (USGFS). While group III (n = 20) included those who treated with endovenous laser therapy (EVLT). The patients were followed up for 6 years.

Results

All selected patients were female aged from 35-62 years with a mean of 47 ± 7.6 years. Thirty-five patients (43.75%) were treated surgically by saphenofemoral junction disconnection (SFJD), and great saphenous vein (GSV) stripping; 25 patients (31.25%) with ultrasound-guided foam sclerotherapy and the remaining 20 patients (25%) were treated with endovenous laser therapy. A significant success rate of GSV ablation was obtained for the endovenous laser therapy treated group over the ultrasound-guided foam sclerotherapy treated patients (P = .023). There was no significant difference between the surgically treated group and those group treated with endovenous laser therapy (P = .85). Recurrence was observed following long-term follow-up after 6 years in 8.5% in group I, 36% in group II, and 10% in group III, respectively. Venous clinical severity score (VCSS) and health-related quality of life score (HRQOLS) improved significantly in all treated groups.

Conclusions

Long-term follow-up of patients with primary superficial varicosities among females is mandatory to elucidate the postoperative recurrence, especially those who underwent ultrasound-guided foam sclerotherapy. In addition to the observation of the development of newly formed varicosities in susceptible individuals which might develop later following long-term follow-up.

Endovascular laser treatment of incompetent saphenous veins using the 1470 nm diode laser and radial fiber

Objectives

To assess the technical success, complications, and patients' quality of life (QoL) after treatment of chronic venous disease (CVD) using the 1470 nm radial fiber laser.

Methods

A total of 170 patients with chronic venous disease, classified as C2 to C4 according to CEAP classification, were treated for incompetent greater (GSV) and small (SSV) saphenous veins, using the 1470 nm radial fiber laser and application of tumescent anesthesia. Additional phlebectomies were performed through stab microincisions, while 11 patients further underwent sclerotherapy intraoperatively. Patients' QoL was recorded using a CIVIQ-20 questionnaire pre and post-operatively.

Results

Technical success regarding GSV vein occlusion was recorded at 100% and 98% during 12 and 24 month follow up respectively. SSV occlusion rates were recorded at 100% for the same period. 55% of patients were classified as C2. Mean laser application time was 401.1 ± 92.6 s and 169.4 ± 56.8 s, while an average of 3986.6 ± 934.9 and 1643.5 ± 534.1 J were applied during ablation of GSV and SSV respectively. Three incidents of postoperative pain were recorded. Two patients exhibited partial proximal GSV recanalization, while two patients reported mild post-operative temporal paresthesia. No major complications were observed post-operatively. A significant improvement in patients' QoL was demonstrated through the CIVIQ-20 questionnaires. Mean pre-operative CIVIQ-20 total score was recorded at 77 ± 3.9, with a total score of 32.8 ± 2.8 being observed during 12 month follow-up.

Conclusions

Endovascular laser treatment using the 1470 nm radial fiber laser constitutes an effective and safe modality for treatment of CVD.

•

Chronic venous disease (CVD) is one of the most commonly encountered health issues regarding venous disorders.

•

A paradigm shift has occurred in the 21st century regarding its treatment, offering less invasive treatment options.

•

This study was conducted in a series of 170 patients who were treated for CVD the 1470 nm diode laser with radial fiber.

•

Technical success rate was excellent with only a few minor incidents of post operative complications.

•

Patients' quality of life was drastically improved as it was recorded using a CIVIQ-20 questionnaire.

Long great saphenous vein grafting as temporary coronary bypass for extended left hepatectomy: report of a case

The right gastroepiploic artery (RGEA) has been used in coronary artery bypass grafting (CABG) as an alternative graft. In particular abdominal surgeries, surgery is required to rescue the graft flow into the coronary artery. A 77-year-old male with a history of CABG using RGEA was admitted with a diagnosis of a large hepatocellular carcinoma (HCC) occupying the whole caudate lobe. Preoperative coronary angiography indicated that the graft from the right internal mammary artery to the proximal left circumflex artery was obliterated among three branch bypasses. Following laparotomy, a great saphenous vein was harvested and delivered from the right axial artery to the RGEA graft over the thoracic wall, and the RGEA graft was ligated and divided. Subsequently, extended left hepatectomy was safely performed. Following hepatectomy, the RGEA graft was restored to the former condition, and the temporary graft was removed. After overcoming hyperbilirubinemia, the patient was discharged on postoperative day 28. This experience indicates that temporary bypass using the long great saphenous vein is effective and safe during long and invasive surgeries.

Retrograde mechanochemical ablation of the small saphenous vein for the treatment of a venous ulcer

We present the first case of retrograde ablation of the small saphenous vein to treat active venous ulceration. A 73-year-old gentleman with complicated varicose veins of the left leg and a non-healing venous ulcer despite previous successful endovenous treatment to his left great saphenous vein underwent mechanochemical ablation of his small saphenous vein with the ClariVein® system, under local anaesthetic, using a retrograde cannulation technique. Post-operatively the patient had improved symptomatically and the ulcer size had reduced. This report highlights that patients with small saphenous vein incompetence and active ulceration can be treated successfully with retrograde mechanochemical ablation.

The effect of short saphenous vein stripping in patients with deep venous reflux

OBJECT

We assessed whether or not deep venous reflux (DVR) improved after short saphenous vein (SSV) stripping was performed in patients with SSV reflux and DVR.

MATERIALS AND METHODS

Sixty-eight patients with SSV reflux who underwent SSV striping every Monday between 2008 and 2011 at Ryougoku Ashino Clinic were enrolled in this study. Forty-six of the 68 patients were selected for the analysis because they underwent duplex ultrasound examinations before and after the operation. The DVR was classified into four categories: type 0, no reflux; type I, reflux in popliteal vein; type II, reflux from popliteal vein to the middle of the superficial femoral vein (SFV) and type III, reflux from the popliteal vein to the SFV.

RESULTS

There were 23, 13, 2 and 8 patients with type 0, I, II, III before operation, respectively. There were 33, 8, 1, 4 patients with type 0, I, II, III after operation, respectively. There were no changes in 29 patients, improvement in 15 and new DVR in three (type 0 to I).

CONCLUSION

SSV stripping is feasible in patients with DVR and the DVR might not be deteriorated even though that is performed.

Evaluation of prosthetic venous valves, fabricated by electrospinning, for percutaneous treatment of chronic venous insufficiency

Chronic venous insufficiency (CVI) remains a major health problem worldwide. Direct venous valve surgical repair and venous segment transplantation are clinical options; however, they are highly invasive procedures. The objectives of this study were to fabricate prosthetic venous valves (PVVs) by electrospinning, for percutaneous treatment of CVI, and evaluate their hydrodynamic characteristics in vitro at the same locations and under the same flow conditions. The PVVs consisted of polyurethane fiber scaffolds attached to a cobalt-chromium stent. PVVs with two different valve-leaflet configurations were compared: biomimetic PVV (bPVV) and open PVV (oPVV). A balloon catheter was used to implant the devices in a poly(vinyl chloride) tube and the column outlet was set at a height of 100 cm above the test valve to simulate the elevation of the heart above a distal vein valve while standing; 50 wt% glycerin solution was used as the test fluid. The devices were evaluated for antegrade flow, effect of ankle flexion, and stagnation zones around the valve leaflets. During sudden hydrostatic backpressure, little leakage and constant peripheral pressure were observed for the devices; under forward pulsatile pressure of 0-4 mmHg, to simulate the effect of breathing, the oPVV had a higher flow rate than the bPVV. With regard to the effect of ankle flexion, the oPVV was functionless. Moreover, the stagnation zone around the oPVV valve leaflets was larger than that around the bPVV valve leaflets. These results suggest that the bPVV would be clinically suitable for percutaneous treatment of CVI.

The aetiology and influence of age and gender on the development of advanced chronic venous insufficiency in the population of patients of semi-urban county outpatient vascular clinic in Poland

Objective

To determine the aetiology and influence of age and gender on the development of advanced chronic venous insufficiency in patients of semi-urban county outpatient vascular clinic.

Methods

One hundred and fourteen patients with venous ulcers were divided, based on the ultrasound examination, into group 1 or group 2, with or without post-thrombotic lesions in the deep venous system, respectively. The control group consisted of 352 patients with varicose veins and without leg ulceration. The demographic data and thrombotic risk factors were compared between the groups.

Results

Group 1 patients ( n = 109) were older than group 2 patients ( n = 5) and control group patients, 64.7 versus 47.2 years ( P = 0.016) and versus 53.8 years ( P < 0.001), respectively. The percentage of women did not differ between group 1 and the control group, but was lower in group 2 ( P = 0.01). The history of lower limb fracture or severe trauma increased the risk of post-thrombotic syndrome (PTS) in patients with venous ulcer.

Conclusion

In the population studied, the venous leg ulcer develops mainly due to primary varicose veins and its risk increases with age and is equal for both sexes. PTS should be suspected in younger patients with a history of severe trauma or leg fracture.

Randomized clinical trial of VNUS® ClosureFAST™ radiofrequency ablation versus laser for varicose veins

Background

Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) are both associated with excellent technical, clinical and patient-reported outcomes for the treatment of varicose veins. The aim of this study was to compare the techniques in a randomized clinical trial.

Methods

Consecutive patients with primary great saphenous vein reflux were randomized to EVLA (980 nm) or RFA (VNUS® ClosureFAST™) at a single centre. The primary outcome measure was postprocedural pain after 3 days. Secondary outcome measures were quality of life at 6 weeks, determined by the Aberdeen Varicose Vein Questionnaire (AVVQ) and Short Form 12 (SF-12®), and clinical improvement assessed by the Venous Clinical Severity Score (VCSS). Analyses were performed on the basis of intention to treat using multivariable linear regression.

Results

Some 131 patients were randomized to EVLA (64 patients) or RFA (67). Mean(s.d.) pain scores over 3 days were 26·4(22·1) mm for RFA and 36·8(22·5) mm for EVLA (P = 0·010). Over 10 days, mean(s.d.) pain scores were 22·0(19·8) mm versus 34·3(21·1) mm for RFA and EVLA respectively (P = 0·001). The mean(s.d.) number of analgesic tablets used was lower for RFA than for EVLA over 3 days (8·8(9·5) versus 14·2(10·7); P = 0·003) and 10 days (20·4(22·6) versus 35·9(29·4) respectively; P = 0·001). Changes in AVVQ, SF-12® and VCSS scores at 6 weeks were similar in the two groups: AVVQ (P = 0·887), VCSS (P = 0·993), SF-12® physical component score (P = 0·276) and mental component score (P = 0·449).

Conclusion

RFA using VNUS® ClosureFAST™ was associated with less postprocedural pain than EVLA. However, clinical and quality-of-life improvements were similar after 6 weeks for the two treatments. Registration number: ISRCTN66818013 (http://www.controlled-trials.com).

Chronic venous disorders: Correlation between visible signs, symptoms, and presence of functional disease

BACKGROUND

The aim of this study was to investigate the frequency of chronic venous disorders (CVD) in different demographic groups in Italy and to provide correlations between patterns of valve incompetence and clinical feature of disease severity.

METHODS

Advertisements in television and newspapers in 53 Italian cities were used to solicit 16,251 subjects (13,826 women, mean age 50.4 years; 2,425 men, mean age 59.1 years). They underwent a clinical examination of the lower limbs, including presence and severity of visible signs (CEAP classification), and assessment of functional disease by color-coded duplex ultrasound imaging.

RESULTS

Varicose veins and telangiectases were the most common objective signs in both men and women. Older people were more severely affected. Telangiectases were more frequent in women, and men had a higher incidence of trunk varices, trophic changes, and venous reflux. Frequency of both visible and functional venous disease increased with family history and body mass index. Presence of reflux correlated positively with increasing CEAP grade of visible disease (Pfor trend < .0001 for all superficial venous segments). A large number of subjects, especially women, complained of subjective symptoms in the legs, and the presence of symptoms correlated almost always positively with both worsening of visible findings (P for trend < .001) and presence of hemodynamic change in both genders.

CONCLUSIONS

The frequency of reflux increased with the severity of visible signs of disease as described by the CEAP classification. In men, the occurrence of subjective symptoms was mostly correlated with functional disorders.

Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial

OBJECTIVE

To determine whether recurrence of leg ulcers may be prevented by surgical correction of superficial venous reflux in addition to compression.

DESIGN

Randomised controlled trial.

SETTING

Specialist nurse led leg ulcer clinics in three UK vascular centres.

PARTICIPANTS

500 patients (500 legs) with open or recently healed leg ulcers and superficial venous reflux.

INTERVENTIONS

Compression alone or compression plus saphenous surgery.

MAIN OUTCOME MEASURES

Primary outcomes were ulcer healing and ulcer recurrence. The secondary outcome was ulcer free time.

RESULTS

Ulcer healing rates at three years were 89% for the compression group and 93% for the compression plus surgery group (P=0.73, log rank test). Rates of ulcer recurrence at four years were 56% for the compression group and 31% for the compression plus surgery group (P<0.01). For patients with isolated superficial reflux, recurrence rates at four years were 51% for the compression group and 27% for the compress plus surgery group (P<0.01). For patients who had superficial with segmental deep reflux, recurrence rates at three years were 52% for the compression group and 24% for the compression plus surgery group (P=0.04). For patients with superficial and total deep reflux, recurrence rates at three years were 46% for the compression group and 32% for the compression plus surgery group (P=0.33). Patients in the compression plus surgery group experienced a greater proportion of ulcer free time after three years compared with patients in the compression group (78% v 71%; P=0.007, Mann-Whitney U test).

CONCLUSION

Surgical correction of superficial venous reflux in addition to compression bandaging does not improve ulcer healing but reduces the recurrence of ulcers at four years and results in a greater proportion of ulcer free time.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN07549334 [controlled-trials.com].

Residual varicose veins below the knee after varicose vein surgery are not related to incompetent perforating veins

OBJECTIVE

The objectives of this study were to investigate the occurrence of residual varicose veins (visible and ultrasonic) at the below-knee level after short-stripping the great saphenous vein (GSV) and to investigate the possible role of preoperative incompetent perforating veins (IPVs) on the persistence of these varicose veins.

METHODS

In this prospective study in 59 consecutive patients (74 limbs) with untreated primary varicose veins, a preoperative clinical examination and preoperative color flow duplex imaging were performed. Re-evaluation (clinical examination and color flow duplex imaging) was performed 6 months after surgery. Dissection of the saphenofemoral junction and short-stripping of the GSV from the groin to just below the knee level was performed without additional stab avulsions on the lower leg. The association between postoperative reflux in the three GSV branches below the knee level and preoperative IPV and the association between postoperative visible varicose veins in the GSV below knee level and preoperative IPV were determined with odds ratios with the help of a univariate and multivariate logistic regression analysis.

RESULTS

Preoperative varicosities in the GSV below the knee were visible in 62 limbs (70%) and were visible after surgery in 12 limbs (16%). The number of limbs with reflux in the 3 below-knee GSV branches was as follows: anterior branch, 34 (49%) before surgery and 31 (44%) after surgery; main stem, 59 (79%) before surgery and 62 (91%) after surgery; and posterior branch, 49 (67%) before surgery and 46 (63%) after surgery. No statistically significant association between postoperative reflux in the three GSV branches and preoperative IPV nor between postoperative visible varicose veins and preoperative IPV was found.

CONCLUSIONS

This study shows that reflux in the GSV below knee level after the short-stripping procedure persists in all below-knee GSV branches. Approximately 20% of patients with visible varicose veins in the GSV area below the knee level will have visible varicose veins in this area 6 months after the short-strip procedure. These clinical and ultrasonic residual varicose veins are not significantly related to the presence of preoperative IPV.

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.

Ultrasound-guided foam sclerotherapy combined with sapheno-femoral ligation compared to surgical treatment of varicose veins: early results of a randomised controlled trial

AIM

This study is a prospective randomised controlled trial comparing sapheno-femoral ligation, great saphenous stripping and multiple avulsions with sapheno-femoral ligation and ultrasound guided foam sclerotherapy to the saphenous vein. Primary end points were patient recovery period and quality of life and secondary end points frequency of complications on the two arms of the trial and the cost of the treatment.

MATERIAL AND METHOD

Sixty patients with primary varicose veins due to GSV incompetence and suitable for day case surgery were randomly allocated to undergo ultrasound-guided sclerotherapy with sapheno-femoral ligation under local anaesthesia (n=30) or sapheno-femoral ligation, stripping and multiple avulsions under general anaesthesia (n=30). The study protocol included history, physical examination, assignment of CEAP class and assessment venous clinical severity score (VCSS), completion of the aberdeen vein questionnaire (AVQ) and colour duplex ultrasound.

RESULTS

All treatments were completed as intended. Median time to return to normal activities was significantly reduced in the foam sclerotherapy group (2 days) compared to the surgical group (8 days) (p<0.001, Mann-Whitney). AVQ score was also significantly reduced at 3 months by 46% in the sclerotherapy group, and by 40% in the conventional surgery group (p<0.001, Wilcoxon). The time taken to complete treatment was shorter in the foam sclerotherapy plus SFJ ligation group: 45 vs. 85 min (p<0.001, Mann-Whitney). The overall cost of the procedure in the sclerotherapy group ( 672.97 pounds) was significantly less compared to conventional surgery ( 1120.64 pounds). At 3 weeks, there was no statistical difference in the complication rate between the two groups. At 3 months, median CEAP class dropped from four pre-operatively to one following treatment in both groups and the median VCSS score dropped from five to one in group one and from seven to three in group two (p<0.001, Wilcoxon test). In group one four patients (13%) had a recanalised vein which needed further sessions of foam sclerotherapy, resulting in a short-term closure rate of 87%.

CONCLUSION

Ultrasound guided sclerotherapy combined with sapheno-femoral ligation was less expensive, involved a shorter treatment time and resulted in more rapid recovery compared to sapheno-femoral ligation, saphenous stripping and phlebectomies.

Effect of Superficial Venous Surgery on Venous Function in Chronic Venous Insufficiency

Patients with chronic venous insufficiency often have combined superficial and deep venous incompetence. The aims of this study were to determine the effects of superficial venous surgery (SVS) on deep venous haemodynamics and on ambulatory venous pressure (AVP) and to determine if the AVP tourniquet test can predict the effect of SVS. Of 119 legs, 42 legs (32 subjects) with chronic venous insufficiency, healed ulceration, or active ulceration and with combined superficial and deep incompetence underwent preoperative duplex imaging and AVP measurement followed by appropriate SVS. Four months later, all underwent postoperative duplex imaging and AVP measurement. The pressure relief index (PRI) was calculated from the AVP measurement as an overall assessment of venous function. Seventeen of 119 (14%) showed no tourniquet improvement in PRI and were therefore excluded from SVS. Of those suitable for SVS, median (range) age was 56 (32-78) years. Twenty-two limbs underwent long saphenous surgery, four limbs short saphenous surgery, and 16 limbs both, based on duplex findings. Segmental deep incompetence resolved in 11/21 (52%) limbs after surgery compared to 6/21 (29%) with multisegment incompetence. Median (range) PRI improved from 319 (4-1,600) preoperatively to 1,300 (360-2,670) postoperatively (p < 0.001, Wilcoxon). PRI with thigh tourniquet correlated with postoperative PRI (r = +0.828, p = 0.01, Spearman), as did calf tourniquet (r = +0.996, p = 0.004) and both tourniquets (r = 0.535, p = 0.046). The majority of patients with combined superficial and deep incompetence can be selected for SVS on the basis of AVP measurement with tourniquets. SVS can improve segmental deep incompetence and PRI in those properly selected.

Changes in superficial and perforating vein reflux after varicose vein surgery

OBJECTIVES

This prospective duplex study was conducted to study the effect of current surgical treatment for primary varicose veins on the development of venous insufficiency < or = 2 years after varicose vein surgery.

METHODS

The patients were part of a randomized controlled study where surgery for primary varicose veins was planned from a clinical examination alone or with the addition of preoperative duplex scanning. Postoperative duplex scanning was done at 2 months and 2 years.

RESULTS

Operations were done on 293 patients (343 legs), 74% of whom were women. The mean age was 47 years. In 126 legs, duplex scanning was done preoperatively, at 2 months and 2 years, and at 2 months and 2 years in 251 legs. Preoperative perforating vein incompetence (PVI) was present in 64 of 126 legs. Perforator ligation was not done on 42 of these; at 2 months, 23 of these legs (55%) had no PVI, and at 2 years, 25 legs (60%) had no PVI. Sixty-one legs had no PVI preoperatively, 5 (8%) had PVI at 2 months, and 11 (18%) had PVI at 2 years. In the group of 251 legs, reversal of PVI between 2 months and 2 years was found in 28 (41%) of 68 and was more common than new PVI, which occurred in 41 (22%) of 183 (P = .003). After 2 years, the number of legs without venous incompetence in which perforator surgery was not performed was 11 (26%) of 42 legs with preoperative PVI and 18 (30%) of 61 legs without preoperative PVI, (P = .713). After 2 years, new vessel formation was more common in the surgically obliterated saphenopopliteal junction (SPJ), 4 (40%) of 10, than in the saphenofemoral junction (SFJ), 17 (11%) of 151(P = .027), and new incompetence in a previously normal junction was more common in the SFJ, 11 (18%) of 63, than in the SPJ, 3 (1%) of 226 (P < .001). Reflux in the great saphenous vein (GSV) below the knee was abolished after stripping above the knee in 17 (34%) of 50 legs at 2 months and in 22 legs (44%) after 2 years.

CONCLUSIONS

Varicose vein surgery induces changes in the remaining venous segments of the legs that continue for several months. In most patients, perforators and the GSV below the knee can be ignored at the primary surgery. A substantial number of recurrences in the SFJ and SPJ are unavoidable with present surgical knowledge because they stem from new vessel formation and progression of disease.

The profile of leg symptoms, clinical disability and reflux in legs with previously operated varicose disease

PURPOSE

It is difficult to assess the severity and location of venous insufficiency in legs with recurrent varicose disease. This present purpose was to evaluate the distribution of reflux and the diagnostic role of current classifications in a consecutive series of legs with previously operated varicose disease.

METHODS

A total of 90 legs in a cohort of 66 patients were included. The examination comprised CEAP clinical class, clinical disability score (CDS) and leg symptoms. Colour-flow duplex imaging (CFDI) was used to observe reflux in deep and superficial veins. Details of prior surgery were assessed.

RESULTS

The site of superficial reflux was at the groin in 58% (recurrent or residive vein trunk or unoperated great saphenous vein), and the rate in the popliteal fossa was 11% (unoperated short saphenous vein). In 58% of the legs presenting superficial reflux at groin level, previous surgery at the saphenofemoral junction was noted. A sensation of pain was observed in 74% of the legs, sensation of oedema in 64%, itching in 26 %, and night cramps in 8%, respectively. Only itching was significantly infrequent in uncomplicated (CEAP C 2-3) legs, and in legs with local reflux was restricted to vein tributaries. Higher CDS (classes 2-3) were significantly more frequent among complicated legs (CEAP clinical class C2-3: 22% versus CEAP clinical class C4-6: 77%; p < 0.005). A similar situation was noted when legs with only local reflux were compared to those with more severe reflux (local reflux: 7% versus severe reflux: 48%; p < 0.005).

CONCLUSIONS

Superficial reflux is frequently detected at groin level despite prior surgery. Unstructured evaluation of leg symptoms is not beneficial. Clinical disability scores associate well with the severity of the venous disease.

Randomized clinical trial of routine preoperative duplex imaging before varicose vein surgery

Background

Duplex imaging is used increasingly for preoperative evaluation of varicose veins, but its value in terms of the long-term results of surgery is not clear.

Methods

Patients with primary varicose veins were randomized to operation with or without preoperative duplex imaging. Reoperation rates, clinical and duplex findings were compared at 2 months and 2 years after surgery.

Results

Two hundred and ninety-three patients (343 legs) had varicose vein surgery after duplex imaging (group 1; 166 legs) or no imaging (group 2; 177 legs). In 44 legs (26·5 per cent), duplex examination suggested a different surgical procedure than had been considered on clinical grounds; the procedure was changed accordingly for 29 legs. At 2 months, incompetence was detected at the saphenofemoral or saphenopopliteal junction (or both) in 14 legs (8·8 per cent) in group 1 and in 44 legs (26·5 per cent) in group 2 (P &lt; 0·001). At 2 years, two legs (1·4 per cent) had undergone or were awaiting reoperation in group 1, and 14 legs (9·5 per cent) in group 2 (P = 0·002). In the remainder, major incompetence was found in 19 legs (15·0 per cent) in group 1 and in 53 (41·1 per cent) in group 2 (P &lt; 0·001).

Conclusion

Routine preoperative duplex examination led to an improvement in results 2 years after surgery for patients with primary varicose veins.

A comparison of patients who developed venous leg ulceration before and after their 50th birthday

BACKGROUND

although chronic venous ulceration (CVU) is often viewed primarily as a disease of the elderly, recent epidemiological data suggest that a significant proportion of patients first develop CVU before middle age. Such patients may represent a distinct group in terms of aetiology, natural history, prognosis and therapeutic options.

AIM

to compare patients who developed CVU before (Group 1) and after (Group 2) their 50th birthday.

METHODS

one hundred and eighteen consecutive patients with "pure" CVU underwent history and examination, measurement of ankle-brachial pressure index (ABPI) and duplex ultrasound examination of the affected limb. Pure venous ulcers were defined as those of >4 weeks duration in the presence of venous reflux (>0.5) and in association with an ankle: brachial pressure index of >0.8.

RESULTS

patients in Group 1 (n = 54, 46%) were more likely to be male (32/54 [59%] vs 14/64 [23%], p < 0.001 chi(2)), to have a higher median (interquartile [IQR]) body mass index (32 [27-39] vs 27 [23-34], p = 0.003, Mann-Whitney U [MWU]), to have a history of deep venous thrombosis (23/54 [43%] vs 16/64 [25%], p = 0.04 chi(2)) and of ipsilateral long bone fracture (13/54 [24%] vs 5/64 [8%], p = 0.01, chi(2)), to have previously undergone venous surgery (27/54 [50%] vs 19/64 [30%] a median (IQR) of 11.5 (6.5-19) and 10 (2-20) years earlier respectively, and to have worse disease in terms of the duration of present ulcer (12 (6-36) vs 8.5 [3-18] months, p = 0.035 MWU), the total duration of ulcer disease (216 [72-360] vs 48 [12-120] months, p < 0.001 MWU), and the number of episodes of ulceration (3 [2-7] vs 1 [1-3], p = 0.002 MWU). There was no significant difference between the two groups in the pattern and severity of venous reflux with 46/54 (85%) of Group 1 and 54/64 (84%) of Group 2 patients having surgically correctable superficial venous reflux.

CONCLUSION

patients who develop CVU before their 50th birthday appear to represent a distinct group in terms of aetiology, natural history and prognosis. The importance of thrombo-embolic prophylaxis in the prevention, and the detection and correction of superficial venous reflux in the treatment, of such ulcers is re-emphasised.