Progress in the investigation of chronic venous insufficiency

Ambulatory venous pressure, air plethysmography, and the role of calf venous pump in chronic venous disease

BACKGROUND

Ambulatory venous pressure (AMVP) records pressure dynamics with calf exercise. Air plethysmography (APG) measures related volume detail. APG has been suggested as a noninvasive surrogate for AMVP. We examine the correlations between APG and AMVP parameters and the role of "calf pump failure" in chronic venous disease (CVD).

METHODS

A total of 8456 limbs in 4610 patients investigated for CVD during a 20-year period were analyzed. APG and AMVP data were available in 4599 limbs for calculation of Pearson correlation coefficient; 1347 of these limbs had significant iliac vein stenosis, proven by intravascular ultrasound. Venn diagrams are used to explore overlapping incidence of APG and AMVP abnormalities.

RESULTS

APG calf volume and reflux (venous volume, venous filling index) showed progressively significant deterioration with advancing Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class, anatomic extent of reflux (superficial, deep, perforator), and reflux severity (axial reflux, segmental score). Notably, calf ejection volume increased in a nearly linear fashion (R = 0.71) to venous volume such that residual volume fraction (RVF) remained normal even in the worst of these categories. AMVP too progressively deteriorated with clinical disease and reflux severity. Venous filling time was the key parameter as the pressure drop alone was abnormal in only 4% of the limbs analyzed. There was no correlation between RVF and AMVP (R = 0.22) or between AMVP and many other APG parameters. Venn distribution showed only minor overlap (30%) between AMVP and key APG abnormalities overall, but the overlap increases from 40% to 70% in advanced clinical and reflux categories. AMVP was rarely abnormal (7%) when APG was normal. Median AMVP was normal in calf pump failure categories, however defined (subnormal ejection fraction, RVF, or both). Median AMVP is normal in venous obstruction without reflux, while AMVP abnormalities are associated three to seven times more with reflux than with obstruction.

CONCLUSIONS

APG (venous filling index) is a useful index of reflux. Calf pump ejection is a powerful and plastic compensatory mechanism, and calf pump failure is rare. Ambulatory venous hypertension is dominantly associated with reflux and less with obstruction. AMVP too worsens with clinical and reflux severity categories. However, there is little correlation between APG and AMVP parameters as APG measures volume and AMVP measures pressure, each in its own domain, and the volume-pressure curve is nonlinear. AMVP may be omitted in routine clinical testing if APG is normal, as the yield (7%) will be very low. AMVP reflects venous hypertension, the end stage in CVD. AMVP should be used to identify such cases when APG is abnormal.

The evidence supporting treatment of reflux and obstruction in chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel convened to assess the evidence supporting treatment of chronic venous disease. Several societies addressed the questions posed to the panel. A multidisciplinary coalition, representing nine societies of venous specialists, reviewed the literature and presented a consensus opinion regarding the panel questions. The purpose of this paper is to present our coalition's consensus review of the literature and recommendations for chronic venous disease.

The Effect of Walking With High-Heeled Shoes on the Leg Venous Pressure

It is common belief that the use of high-heeled shoes is deleterious to venous return, by impairing the efficiency of the muscular calf pump. Ambulatory venous pressure obtained with dorsal foot venipuncture is the gold standard in the evaluation of venous pressure during walking, but it is not routinely used in clinical practice. The objective of the present study was to determine the variations in leg venous pressure obtained with a new noninvasive method, in individuals without venous disease, walking without shoes and wearing high-heeled shoes. A new method of evaluation of the venous pressure by means of air plethysmography was applied to 10 volunteers (20 limbs). The patients were evaluated while standing, with ortho-static flexion and extension foot movements, and while walking on a treadmill barefooted and wearing high-heeled shoes. It was found that the variation on the cuff pressure during walking with high-heeled shoes was higher than the variation on the cuff pressure walking barefooted (52.2 ±8.89 x 26.65 ±6.7 mm Hg, p<0.0001), and the final hydrostatic venous pressure was lower (51.5 ±12.78 x 61.5 ±8.44 mm Hg). The use of high-heeled shoes increases muscular effort during walking and diminishes the leg venous pressure compared with barefooted.

Patterns of reflux in the great saphenous vein system

Objective:

To report the patterns of reflux in the great saphenous vein as well as to investigate the correlations between patterns of reflux, the demographics and the clinical findings in the population studied.

Methods:

A total of 1882 limbs were assessed by duplex ultrasound examination in 1449 patients (348 men and 1101 women). Ages ranged from 21 to 94 years (mean 51.8). The presence of symptoms of venous disease (aching, heaviness, night cramps, swelling, itching, burning, tingling and throbbing) and clinical signs were recorded.

Results:

Varicose veins without saphenous reflux occurred at a younger age (43 versus 55.6 years P < 0.05). The presence of incompetence at the saphenofemoral junction occurred in older patients (58.5 versus 54.1 years P < 0.05). Venous reflux to the ankle also occurred in older patients (mean 64.0 years P < 0.05). Saphenous vein reflux without clinical varices was associated with more advanced signs (C4–C6: 20.3% P < 0.05). A younger age was associated with less advanced signs (C0–C2:49.4 versus C4–C6: 60.1 years P < 0.05). Presence of symptoms was associated with advancing patient age (51.1 versus 49.1 years P < 0.05).

Conclusions:

A significant correlation between the extent of great saphenous vein reflux and the patient age and the clinical stage of SVI has been observed in this study. The authors hypothesize that these findings support the concept of early treatment of venous insufficiency before symptomatic and physiological deterioration occurs.

Classification of saphenous refluxes: implications for treatment

Objective

To determine the possible correlations of patient age, symptoms and signs with findings of Doppler duplex examination in limbs with varicose veins.

Methods

A total of 2275 ultrasound examinations were done on 2275 limbs of 1751 patients (421 men and 1330 women). Ages ranged from 21 to 94 years (mean 50). Symptoms of aching, heaviness, burning pain (venous neuropathy) were recorded, and signs of ankle hyperpigmentation, scars of healed ulcers and presence of open venous ulcers were noted.

Results

Presence of symptoms was associated with advancing patient age (50.7 vs. 48.8 years). Varicose veins without great saphenous reflux correlated with younger age (43 vs. 53.5 years). Presence of saphenofemoral junctional incompetence correlated with an older age (54.7 vs. 49.8 years), and reflux to the ankle (Hach stage IV) also correlated with older age (mean 63.7 years). A younger age was associated with less advanced signs (C0–C2: 49.1 vs. C4–C6: 60.1 years). Saphenous vein reflux without clinical varices was associated with more advanced signs (C4–C6: 21.3%).

Conclusions

Ageing is associated with advancing clinical symptoms, signs and increasing multifocal reflux in limbs with venous insufficiency. These facts support the concept of early treatment of venous insufficiency before predictable deterioration occurs.

Prospective evaluation of chronic venous insufficiency based on foot venous pressure measurements and air plethysmography findings

PURPOSE

The purpose of this study was to evaluate lower extremity venous function in patients with chronic venous insufficiency, with foot venous pressure (FVP) measurements and air plethysmography (APG).

METHODS

Eighty-five limbs of 63 patients with a history of chronic venous insufficiency (CVI) from 1995 to 1999 were studied. FVP parameters studied included ambulatory venous pressure (AVP), percent decrease in FVP with manual calf compression (%drop), ratio of increase in FVP over 4 seconds after release of compression (4SR%), and time to 90% recovery of FVP were measured. APG parameters studied included functional venous volume, 90% refilling time (VFT90), venous filling index, ejection fraction, and residual volume fraction.

RESULTS

Venous filling index and 90% refilling time were significantly decreased in limbs with stasis syndrome compared with the control group. AVP, %drop, and 4SR% also showed significantly decrease in limbs with stasis syndrome compared with those without it. AVP, %drop, and 4SR% were significantly different for the primary group compared with the secondary group, whereas no differences were found with regard to any APG parameter.

CONCLUSIONS

APG enables prediction of the presence of CVI, whereas FVP measurements are more useful for evaluation of clinical severity of CVI.

Reproducibility of air plethysmography for the evaluation of arterial and venous function of the lower leg

This study assessed the test-retest reliability of air plethysmographic parameters for the evaluation of arterial and venous function of the lower extremity in normal, healthy adults. Fourteen voluntary subjects underwent air plethysmographic tests on two occasions, 1-2 weeks apart, with three tests being performed at each visit. Test-retest reliability was assessed via correlation coefficients and the intraclass correlations. Differences in the parameters of arterial inflow (AI), venous volume (VV), venous refilling time (VFT), venous refilling index (VFI), ejection volume (EV) and residual fraction (EF) obtained on the two separate occasions were small (r = 0.81 approximately 0.95; ICC = 0.94 approximately 0.99), whereas differences in ejection fraction (EF), residual volume (RV) and venous outflow (OF) measurements were much larger (r = 0.50 approximately 0.61; ICC = 0.58 approximately 0.95). The findings demonstrate that evaluation of blood flow in the lower limbs of healthy individuals using air plethysmography is reliable in test-retest measures, suggesting that this technique represents a sensitive method for quantifying changes in parameters of arterial and venous functions of the lower extremity.

Correlation of Tc-99m-red blood cell phleboscintigraphy with clinical severity of chronic venous disease

Equilibrium red blood cell phleboscintigraphy of the lower limbs for the diagnostic management of chronic venous disease has been proposed. The aim of this study was to verify the correlation of the phleboscintigraphic assessment of chronic venous disease with the clinical grading of the severity of the disease, since other diagnostic modalities have been recently demonstrated a poor and only partial correlation. Equilibrium Tc-99m-red blood cell phleboscintigraphy was performed in 27 patients with chronic venous disease. Scintigraphic images of 52 limbs were classified according to a four-class qualitative grading of the severity of the venous disease, and a quantitative scintigraphic index (saphena /femoral ratio) was assigned to each limb. The scintigraphic qualitative grading showed a highly significant correlation with the clinical grading (Rs=0.82, p<0.01), a good interobserver and intraobserver agreement (86.5% and 92.3%, respectively) and more than 90% sensitivity and specificity to identify the categories "minimal or no chronic venous disease" or "more significant disease" (assessed according to the Bayes theorem). Sensitivity and specificity results for the quantitative assessment were not as good. Phleboscintigraphy correlates well with the clinical grading of the severity of chronic venous disease of the lower limbs and may have potential as a valuable diagnostic tool for the noninvasive assessment of chronic venous disease.

Investigation of chronic venous insufficiency: A consensus statement (France, March 5-9, 1997)

This consensus document provides an up-to-date account of the various methods available for the investigation of chronic venous insufficiency of the lower limbs (CVI), with an outline of their history, usefulness, and limitations. CVI is characterized by symptoms or signs produced by venous hypertension as a result of structural or functional abnormalities of veins. The most frequent causes of CVI are primary abnormalities of the venous wall and the valves and secondary changes due to previous venous thrombosis that can lead to reflux, obstruction, or both. Because the history and clinical examination will not always indicate the nature and extent of the underlying abnormality (anatomic extent, pathology, and cause), a number of diagnostic investigations have been developed that can elucidate whether there is calf muscle pump dysfunction and determine the anatomic extent and severity of obstruction or reflux. The difficulty in deciding which investigations to use and how to interpret the results has stimulated the development of this consensus document. The aim of this document was to provide an account of these tests, with an outline of their usefulness and limitations and indications of which patients should be subjected to the tests and when and of what clinical decisions can be made. This document was written primarily for the clinician who would like to learn the latest approaches to the investigation of patients with CVI and the new applications that have emerged from recent research, as well as for the novice who is embarking on venous research. Care has been taken to indicate which methods have entered the clinical arena and which are mainly used for research. The foundation for this consensus document was laid by the faculty at a meeting held under the auspices of the American Venous Forum, the Cardiovascular Disease Educational and Research Trust, the European Society of Vascular Surgery, the International Angiology Scientific Activity Congress Organization, the International Union of Angiology, and the Union Internationale de Phlebologie at the Abbaye des Vaux de Cernay, France, on March 5 to 9, 1997. Subsequent input by co-opted faculty members and revisions in 1998 and 1999 have ensured a document that provides an up-to-date account of the various methods available for the investigation of CVI.

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

PURPOSE

The purpose of this study was to determine the patterns of isolated lesser saphenous vein (LSV) system incompetence and correlate the distribution and extent of such reflux with symptoms and signs of chronic venous disease (CVD).

METHODS

During a 3-year period, 2254 limbs in 1682 patients with signs and symptoms of CVD were evaluated with color flow duplex scanning. Extremities with isolated reflux in the LSV system were selected for this study. Limbs with perforating venous reflux connected to this system only were also included. Limbs that had marked reflux in the greater saphenous or deep vein, that had a documented history of deep venous thrombosis, and that previously underwent surgery or sclerotherapy were excluded. The clinical severity of the limbs was graded with the CEAP classification system.

RESULTS

There were 226 limbs in 200 patients with reflux in the LSV system; 61% were female patients with a mean age of 49 years (range, 18-82 years). There were 174 patients (87%) with unilateral and 26 with bilateral disease, and 41% of the limbs belonged in CVD class 2, 26% in class 3, 12% in class 4, 3.5% in class 5, and 3% in class 6. Classes 0 and 1 were present in 14.5% of the limbs. Symptoms were present in 139 limbs (61.5%). Some degree of ache or burning sensation was the most frequent symptom (41%), followed by itching (32%), heaviness (29%), cramps (24%), and restless limbs (18%). Reflux in the main trunk of the LSV was the most prevalent (177 limbs [78%]), followed by the saphenopopliteal junction (146 limbs [64.6%]), the vein of Giacomini (39 limbs [17%]) and the gastrocnemial vein (23 limbs [10%]). Reflux involving both the saphenopopliteal junction and the LSV was seen in 50% of limbs, but almost any other combination of reflux was present, which indicated the complexity of this system. Perforator vein incompetence was detected in 56 limbs (25%). We found 83 perforator veins, resulting in a mean of 1.5 veins per limb. Both the number of incompetent perforator veins and the extent of superficial reflux correlated with clinical severity. Four main types of termination of the LSV were identified with at least nine variations. The LSV was duplicated for at least half of its length in five limbs (2.2%). Nonsaphenous reflux was detected in seven limbs (3.1%). Superficial vein thrombosis in the LSV system was found in eight limbs (3.5%), and in the gastrocnemial vein it was found in four (1.8%).

CONCLUSIONS

Isolated LSV system incompetence can cause the entire range of signs and symptoms of CVD. Clinical deterioration is associated with a longer extent of reflux and perforator incompetence. Classes 2 to 4 are the most frequent clinical presentations, whereas classes 5 and 6 are uncommon. The complex anatomy of this system and the great variation in the patterns of reflux warrant the use of color flow duplex scanning before planning treatment.

Endoscopic subfascial perforating vein ligation: its complementary role in the surgical management of chronic venous insufficiency

Endoscopic methods have proven as efficacious as previous open surgical techniques for ligation of calf perforating veins. The reduced incidence of wound complications favors the minimally invasive approach regardless of the technique used. Since isolated disease of the calf perforating veins is rare, most of these procedures are performed in conjunction with superficial venous ablation. These advanced procedures are indicated for patients with skin and subcutaneous manifestations of CVI (CEAP classes 4, 5, and 6). Although the contribution of perforator ligation to the hemodynamic and clinical result is unclear, clinical symptoms and hemodynamics have significantly improved when performed as described.

Developments in diagnosis and classification of venous disorders: non-invasive diagnosis

PURPOSE

This review examines the many techniques that have been used for the non-invasive diagnosis of acute and chronic venous disease and was conducted by members of the Committee on Research of the American Venous Forum. It proposes to identify those techniques with the greatest clinical potential, to suggest algorithms for the clinical application of non-invasive techniques in the identification of acute deep venous thrombosis and chronic venous insufficiency, and to identify areas of deficient knowledge and potential areas for future research initiatives.

METHODS

Review of pertinent clinical and research material.

RESULTS

Impedance plethysmography and ultrasonic imaging are the primary non-invasive tools used in the diagnosis of acute deep venous thrombosis. At present, ultrasonic imaging techniques are recommended on the basis of greater diagnostic accuracy in recent comparative clinical trials. Data would suggest that serial evaluation should probably be viewed as the preferred option for symptomatic patients with a negative initial examination and the presence of risk factors or physical findings suggesting a proximal deep venous obstruction/thrombosis. Chronic venous disease is the result of valvular incompetence, with or without associated venous obstruction. Duplex imaging can be used to determine the location and extent of reflux; however, there are reported procedural variations in the performance and interpretation of such studies. Recent innovations in air plethysmography may provide a means of quantifying volume changes, and permit an objective characterization of venous reflux and calf pump efficiency.

CONCLUSIONS

There are still significant questions that need to be answered by well-designed research initiatives. Research applications that incorporate non-invasive diagnostic techniques may involve the diagnosis, treatment and natural history of acute deep venous obstruction/thrombosis and chronic venous insufficiency, assessment prior to and following venous reconstruction, and the basic science aspects of acute and chronic venous disease. At present, a lack of common standards is, by far, the greatest impediment to an organized research approach to venous disease.

Surgical intervention in venous ulceration

The purpose of this article is to review surgical management for dermal ulceration that results from chronic venous insufficiency. Efficacy is gauged by freedom from recurrent ulceration, an objective clinical monitor. Accurate preoperative diagnosis and postoperative assessment of the venous circulation is enhanced by reliable non-invasive examinations. A recently developed clinical classification unifies reporting criteria and has been widely subscribed. Standard surgical ablation of incompetent saphenous and other superficial veins significantly improves clinical and hemodynamic outcome. Perforator incompetence alone is rarely the cause of ulcerative disease, but adjunctive ligation of communicating veins is considered important to the effective elimination of chronic venous insufficiency. New endoscopic techniques reduce morbidity associated with long incisions from the open subfascial procedure. In a more advanced role, deep venous reconstruction is infrequently performed, but is quite durable. Free-tissue transfer appears to be effective after 2 years of observation. Post-thrombotic chronic venous insufficiency continues to confer a more severe prognosis, which emphasizes the importance of accurate and precise diagnosis. Investigation of patients with ulcerative chronic venous insufficiency should be actively pursued, since individualized surgical management will effectively reduce recurrence of ulceration.

Venous hemodynamics of the lower extremities in response to electrical stimulation

OBJECTIVE

To evaluate the calf muscle pump function using an air plethysmograph (APG) applied to the lower leg of subjects during three different tiptoe exercises.

DESIGN

A controlled trial design was selected to compare the hemodynamic effects of three exercise conditions on a group of able-bodied, healthy patients.

SETTING

Testing was performed in an outpatient clinic at a rehabilitation hospital.

SUBJECTS

Patient groups were selected from a convenience sample of 10 healthy volunteers with normal venous capacitance and no reflux, determined through impedance pleythysmography before the study.

INTERVENTIONS

Three exercise conditions undertaken by each subject consisted of loaded and unloaded lower leg muscle contractions produced by (1) voluntary contraction (VOL), (2) electrical stimulation of the gastocnemius-soleus and tibialis anterior muscles (ES), and (3) combined ES and VOL (ES/VOL).

MAIN OUTCOME MEASURE

Hemodynamic measurements of venous filling index upon standing from the supine (VFI), ejection fraction (EF), ejection volume (EV), residual volume (RV), and residual volume fraction (RVF) were recorded after each protocol. These results were used to compare the lower leg hemodynamic effects of the treatments.

RESULTS

Combined ES/VOL single tiptoe exercise produced the highest EV (97.8mL), followed by VOL (80.6mL) and ES (51.7mL) (p < .0008). The EF was also highest for combined ES/VOL (73.1%), followed by VOL (64.5%) and ES (37.8%) (p < .0001). Ten tiptoe ES exercises produced the highest RV (96.2mL), followed by ES/VOL (44.7mL) and VOL (28.2mL) (p < .0001). RVF was also highest in the ES group (71%), followed by ES/VOL (33.4%) and VOL (22.8%) (p < .0001).

CONCLUSION

Periodic single ES-induced calf muscle contractions produced significant muscle pump function and could be used to improve venous blood flow and reduce stasis in the lower leg. Continuous ES-induced contractions, on the other hand, could improve lower leg peripheral perfusion while eliciting the physiologic venous muscle pump. Higher RV and RVF after 10 ES-induced contractions in this sample of healthy subjects with normal VFI may be caused by an increase in arterial blood perfusion after repeated ES-induced contractions.

A new method for the assessment of venous insufficiency in primary varicose veins using near-infrared spectroscopy

PURPOSE

Patients with chronic venous insufficiency (CVI) were evaluated from the aspect of ambulatory venous function using near-infrared spectroscopy (NIRS).

METHODS

Seventy-two primary varicose veins of 59 patients (varicose group) and 20 normal limbs of 13 volunteers (normal group) were studied. The affected limbs of the patients were divided into three groups according to the classification advocated by an International Consensus Committee in 1995: mild CVI with class 2 or 3 (50 limbs); moderate CVI with class 4 (11 limbs); and severe CVI with class 5 or 6 (11 limbs). All of the patients underwent a treadmill walking test, during which NIRS was applied. Oxygenated hemoglobin (OxyHb) and deoxygenated hemoglobin (DeoHb) were continuously measured by NIRS during exercise. The ambulatory venous retention index (AVRI) obtained from serial changes in DeoHb was assessed comparatively in the four groups (normal and mild to severe CVI). In addition, 19 limbs in 13 patients were evaluated with air plethysmography for comparison with the data obtained by NIRS.

RESULTS

Two distinct patterns of DeoHb change were observed. During exercise, the DeoHb level decreased in the normal group as a result of calf muscle contraction, whereas in the varicose group the DeoHb level rose because of an apparent venous reflux into the calf muscles. AVRI studies demonstrated a significant difference (p < 0.0001) among groups. Although there was no apparent relationship between AVRI and ejection fraction, AVRI showed a significant correlation with the venous filling index (r = 0.61) and a weak correlation with the residual volume fraction (r = 0.41).

CONCLUSION

NIRS is useful for accurately assessing ambulatory venous dysfunction in patients with primary varicose veins.

A correlation of air plethysmography and color-flow-assisted duplex scanning in the quantification of chronic venous insufficiency

PURPOSE

Air plethysmography has been useful in assessing patients who have chronic venous insufficiency. Limb reflux times determined by color-flow-assisted duplex scanning have been shown to correlate with the severity of chronic venous insufficiency. The purpose of this study was to compare air plethysmographic measurements with reflux times obtained by color-flow-assisted duplex scanning in patients with chronic venous insufficiency.

METHODS

One hundred twenty-two limbs in 61 consecutive patients with various stages of chronic venous insufficiency were evaluated; air plethysmographic and color-flow-assisted duplex scans were performed at the same sitting. Fifty-nine of the patients had venous ulceration. Values obtained by air plethysmographic scans included venous filling index, ejection volume, residual volume, ejection fraction, and residual volume fraction. Color-flow-assisted duplex scan values included reflux times in the deep and superficial venous segments and total and mean limb reflux times.

RESULTS

Using the Pearson correlation, the venous filling index was found to correlate significantly with total limb venous reflux times, mean total limb reflux times, and venous reflux times in the deep venous system, as determined by color-flow-assisted duplex scans (p < 0.001).

CONCLUSIONS

Limb reflux time as determined by color-flow-assisted duplex scans correlated significantly with the air plethysmographic variable accepted as a measure of the severity of venous reflux, the venous filling index. This study confirms the validity of total limb reflux times in the quantification of chronic venous insufficiency.

The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency

PURPOSE

The purpose of this study was to identify the distribution of venous reflux in patients with different patterns of reflux with each class.

METHODS

Color-flow duplex imaging was used to evaluate the entire venous system from groin to ankle in 465 patients (594 limbs) belonging to different clinical CVI classes (0, 1, 2, and 3). A history of previous superficial thrombophlebitis was present in five limbs and past deep vein thrombosis in 70.

RESULTS

One hundred seventy eight (30%) limbs were normal and the remaining 416 (70%) had venous incompetence. Deep reflux was present exclusively in 19 limbs (3.2%), and the perforation system alone was involved in only three limbs (0.5%). However, isolated superficial incompetence was seen in 186 limbs (31.3%) and a combination of superficial with perforating alone was involved in 45 (7.6%). Incompetence in all three systems was seen in 99 extremities (16.7%). In addition, the superficial system was involved in 390 limbs, the perforators in 151, and the deep system in 178 limbs. Only a small percentage of those in class 0 had reflux, and most of them had a single site of incompetence. In class 1 the majority of the limbs had superficial reflux (90.3%), 10.3% of the limbs had deep venous reflux, and 6.9% were competent. Reflux in the superficial system was only seen in 80.7% of the limbs in class 1 and in one fifth of the limbs in classes 2 and 3. Isolated deep or perforated incompetence was rare in all classes. Variable combined patterns of reflux were seen more often in classes 2 and 3 (p < 0.0001). In classes 2 and 3 there were no differences in the number of incompetent sites in the superficial and deep venous systems or the patterns of reflux (p > 0.1). The number of incompetent perforators in class 3 tended to be higher than that in class 2, especially in the below-knee segment, but no significant differences were seen. Distal reflux was present in the majority of the limbs in all symptomatic classes (1, 2, and 3).

CONCLUSIONS

The distribution and extent of reflux is strongly associated with clinical severity of CVI through class 2. Distal venous reflux is present in at least 80% of the symptomatic limbs. Deep venous thrombosis may not be a prerequisite for the development of skin changes or ulceration in about 75% of the limbs. Superficial venous surgery could be beneficial to at least one third of patients with skin changes or ulceration.

Venous valvular reflux in veins not involved at the time of acute deep vein thrombosis

PURPOSE

The aim of this study was to determine whether, in lower extremities with documented episodes of acute deep venous thrombosis (DVT), incompetence develops in veins that were not the site of thrombosis.

METHODS

Patients were monitored with serial duplex ultrasonography at 1 day, 1 week, 1, 3, 6, 9, and 12 months, and then annually after detection of acute DVT. The following venous segments were analyzed: common femoral, greater saphenous, proximal superficial femoral, deep femoral, popliteal, and posterior tibial. The incidence of reflux development in both thrombosed and uninvolved segments was determined. Reflux was categorized as either transient or permanent.

RESULTS

A total of 227 limbs in 188 patients were serially studied. Mean follow-up was 19.9 months (range 1 to 88 months). Overall, 403 of the 1423 segments (28.3% +/- 2.3%) developed reflux during the study, of which 118 (29.3% +/- 4.4%) had no prior or concurrent history of thrombosis. Considering only the segments that developed incompetence, the percent without prior thrombosis at each level was as follows: common femoral vein (40.0%), greater saphenous vein (53.1%), deep femoral vein (20.6%), proximal superficial femoral vein (23.9%), popliteal vein (8.9%), and posterior tibial vein (31.9%). Valvular insufficiency developing in segments uninvolved with thrombus was more likely to be transient (40.2%) than was the reflux in thrombosed segments (22.6%). This difference was statistically significant (p < 0.05).

CONCLUSIONS

Permanent venous valvular damage can occur in the absence of thrombosis after DVT. Reflux in uninvolved venous segments has a different anatomic distribution and is more likely to be transient than the incompetence associated with thrombosis.

Duplex ultrasound assessment of the venous status of the swollen leg

Between January 1991 and December 1993, duplex ultrasound characterization of venous disease in leg swelling was studied in 214 patients (261 limbs; 167 unilateral and 47 bilateral). All patients were examined with a duplex scanner, the superficial and deep venous systems were evaluated for the presence of thrombus and valvular incompetence. Of the 261 limbs, 29 (11.1%) had deep venous thrombosis, 14 (5.4%) had superficial venous thrombosis, 66 (25.3%) had deep venous incompetence (31/66 limbs also had superficial venous incompetence), 65 (24.9%) had incompetence in the superficial veins only, and five (1.9%) had deep venous obstruction resulting from a popliteal cyst or a popliteal vein ligation. Eighty-two limbs (31.4%) had no evidence of venous obstruction or incompetence at the areas evaluated. This study showed that venous obstruction and valvular incompetence had occurred in two-thirds of swollen legs examined. Some of the venous obstructions resulted from surgically treatable diseases such as a popliteal cyst, and some of the venous disorders involved the superficial venous system only. Complete venous evaluation with duplex imaging can be very helpful in the determination of the underlying cause of the swelling.

Superficial venous insufficiency: correlation of anatomic extent of reflux with clinical symptoms and signs

PURPOSE

The aim of this study was to assess the distribution and extent of valvular incompetence in patients with reflux confined to the superficial venous system and correlate the extent of such reflux with clinical symptoms and signs.

METHODS

Two hundred fifty-five limbs of 217 patients with superficial venous insufficiency and normal perforating and deep veins were examined with color-flow duplex imaging. One hundred twenty-three limbs (48.2%) of 102 patients had reflux confined to the long saphenous system, 83 limbs (32.6%) of 72 patients had reflux confined to the the short saphenous system, and 49 limbs (19.2%) of 43 patients had reflux in both long and short saphenous systems.

RESULTS

In the long saphenous system the commonest pattern of reflux was that which extended throughout the length of long saphenous vein (LSV) (47%). Ache, swelling, and skin changes were common in the presence of below knee reflux irrespective whether the thigh segment was involved. Ulceration (8%) was found only in limbs with reflux extending throughout the length of LSV. In the short saphenous system the most common pattern of reflux extended throughout the length of short saphenous vein (SSV) (57%) without involvement of Giacomini or gastrocnemial veins. Ache and swelling were present in 62% and 72% of the limbs, but this incidence was not related to the extent of reflux. Swelling, skin changes, and ulceration occurred only when the whole of the SSV was involved. In the limbs with reflux in both the long and short saphenous systems, the most common pattern of reflux extended throughout the length of both systems (45%). In these limbs the incidence of swelling was 80%. The incidence of skin changes went from 44% when the below-knee segment of the LSV was involved to 73% when reflux occurred throughout the LSV and SSV. Ulceration (14%) was found only in the latter situation. Variable patterns of saphenogastrocnemial termination were seen. In 57.8% of the limbs SSV joined the popliteal vein just above the popliteal crease, whereas the SSV terminated in the thigh in 26.6%.

CONCLUSIONS

We conclude that ache, ankle edema, and skin changes in limbs with reflux confined to the superficial venous system are predominantly associated with reflux in the below-knee veins. Ulceration is found only when the whole of the LSV is involved (8%) or when reflux is extensive in both LSV and SSV (14%).

An anatomic source of false venous reflux with continuous wave Doppler

BACKGROUND

The limitations of continuous wave (CW) Doppler have been recognized in the assessment of venous reflux since CW Doppler is not able to distinguish reflux signals from more than one vein. In our experience, some regions with venous reflux suggested by CW Doppler were noted to have no reflux in any individual vein during duplex studies.

OBJECTIVE

The aim of the study was to assess the anatomic source of the venous reflux suggested by CW Doppler but not confirmed by duplex ultrasound.

METHODS

Five hundred and fifty-one consecutive lower limbs with primary or recurrent varicose veins were examined with CW Doppler and subsequently by color-coded duplex ultrasound to assess the source of venous reflux.

RESULTS

The duplex ultrasound study revealed no reflux in 44 specific regions (8%) where reflux had been indicated by CW Doppler. Two types of anatomy were noted. Two or more superficial veins joined the deep venous system via a common junction in 25 cases. A descending vein joined the deep venous system in 19 cases.

CONCLUSION

A bidirectional Doppler signal in a region of venous junction without any incompetent veins can be misinterpreted as venous reflux. A careful examination of veins not only at the region of the junction, but also at some distance down the stem of the vein is important during CW Doppler or duplex assessment.

Duplex scanning and light reflection rheography in the assessment of the severity of short saphenous vein incompetence

BACKGROUND

Duplex ultrasound assessment of veins in the popliteal fossa is an accepted alternative to venography. Light reflection rheography provides additional quantitative information on venous reflux in chronic venous insufficiency.

OBJECTIVE

To use duplex ultrasound and light reflection rheography to study the venous reflux patterns in the popliteal fossa in a group of patients.

METHODS

Duplex ultrasound examination and light reflection rheography were used in the assessment of the severity of short saphenous vein incompetence.

RESULTS

The study revealed that any associated deep venous reflux which was detectable beyond the saphenopopliteal junction represented a more advanced stage of superficial venous insufficiency.

CONCLUSIONS

Light reflection rheography, as a semiquantitative test, provided useful additional information to duplex scan findings in assessing venous reflux of the popliteal fossa. Short saphenous vein reflux with functional deep venous incompetence was associated with shorter venous refilling times and clinically represented a more advanced stage of primary varicose vein disease.

Patterns of venous reflux in limbs with skin changes associated with chronic venous insufficiency

The distribution of venous reflux in patients with skin changes associated with chronic venous insufficiency presenting to a specialist clinic was assessed. A total of 300 limbs in 153 patients were examined by Doppler ultrasonography with colour-flow imaging for the presence of venous reflux in superficial veins, deep veins and medial perforating veins, both above and below the knee. Ninety-eight limbs had skin changes, which included hyperpigmentation, lipodermatosclerosis, atrophie blanche and ulceration. Of this group, 2 per cent had no evidence of venous reflux on duplex scanning, 39 per cent had deep vein incompetence, 57 per cent had superficial vein incompetence and 2 per cent had isolated medial perforating vein reflux. Of 25 limbs with ulceration, 13 had superficial and 12 deep vein reflux. A total of 202 legs, which included 20 normal control limbs, had no skin changes; 22.3 per cent of these had no venous reflux, 8.4 per cent had deep vein incompetence, 65.3 per cent had superficial incompetence and 4.0 per cent had isolated medial calf perforating vein incompetence.

Exercise strain-gauge venous plethysmography: evaluation of a "new" device for assessing lower limb venous incompetence

Plethysmography can be used to detect and assess venous incompetence in the lower extremities. The authors recently evaluated a new device designed for this purpose that uses strain gauges to determine changes in lower extremity circumference occurring with (and immediately after) exercise. The device plots a curve of volume against time for each limb and automatically calculates key values such as the volume of blood expelled from the lower limb veins during exercise and the time required for the veins to refill following exercise. The apparatus was incorporated into their noninvasive vascular laboratory and used (along with other standard tests) to study patients referred for suspected venous incompetence. They observed the following: (1) A shortened postexercise refilling time accurately identified limbs with venous incompetence. (2) The clinical severity of venous incompetence was inversely related to the refilling time. (3) Exercise-induced changes in lower extremity volume correlated well with simultaneously determined changes in venous pressure. (4) Valvular incompetence could be localized to the deep or superficial veins based upon the improvement in refilling times seen following placement of elastic tourniquets around the lower limb. (5) The type of exercise performed (knee bends while the patient was standing versus ankle reflexes while sitting) had little effect on results. The authors conclude that exercise venous plethysmography is a useful noninvasive tool for assessing lower limb venous incompetence.

Impact of duplex scanning on vascular surgical practice

This review outlines the development of duplex scanning over the past 15 years and its value not only in vascular medicine and surgery but also in the field of transplantation and obstetrics. It is now the first line of investigation of patients with symptomatic carotid bifurcation disease and those with clinically suspected acute deep venous thrombosis. It is also an established method of femoropopliteal and femorodistal arterial graft surveillance, determination of the extent and cause of chronic venous insufficiency, detection of placental insufficiency and portasystemic shunt patency, early transplant monitoring, as well as of detecting an arterial stenosis suitable for angioplasty. In addition, it is developing into the method of choice for the initial investigation of patients with suspected mesenteric or renal artery stenosis. The accuracy of duplex scanning, avoiding further unnecessary invasive and expensive diagnostic procedures, makes it one of the most cost-effective investigations ever introduced into clinical practice. Also, when used as a screening technique in arterial and venous disease, it selects those patients who need more invasive procedures such as angiography. This helps to reduce waiting lists of patients requiring investigation, and better directs limited resources to treatment rather than investigation.

Haemodynamic significance of incompetent calf perforating veins

A total of 149 consecutive unselected patients (221 limbs) who presented with signs and symptoms of chronic venous problems (varicose veins with or without ankle oedema, skin changes and leg ulcers) have been studied by clinical examination, ascending deep to superficial venography, Doppler ultrasound and ambulatory venous pressure measurements. Of the limbs, 180 (82 per cent) had varicose veins without obstruction in the deep veins or reflux in the popliteal or femoral veins while 41 (18 per cent) had deep venous disease. Of the 180 limbs with 'primary' varicose veins 110 (60 per cent) did not have incompetent calf perforating veins (group A) while 70 (40 per cent) did (group B). On the basis of the ambulatory venous pressure after calf muscle exercise and the refilling time, the incompetent calf perforating veins of limbs in group B belonged to three subgroups of different haemodynamic significance. In 20 limbs (30 per cent) they were found to be of no haemodynamic significance, in 25 (35 per cent) of moderate haemodynamic significance and in 25 (35 per cent) of major haemodynamic significance. The last were, on clinical examination, indistinguishable from limbs with deep venous disease although they had patent deep veins with competent popliteal valves.