Comparative Study of Duplex-Guided Foam Sclerotherapy and Duplex-Guided Liquid Sclerotherapy for the Treatment of Superficial Venous Insufficiency

PURPOSE

To compare the preliminary results of hemodynamic changes between duplex-guided foam sclerotherapy and duplex-guided liquid sclerotherapy.

METHODS

Seventy Seven limbs in 77 patients with isolated greater saphenous vein incompetence were treated with duplex-guided sclerotherapy. Thirty Seven limbs were treated with duplex-guided foam sclerotherapy and the remaining 40 limbs were treated with duplex-guided liquid sclerotherapy. Pretreatment exam was performed using a color duplex scanner and air plethysmography. The sclerosing foam was produced by Tessari's method using 1% and 3% polidocanol. The varicose vein was injected with 2 mL of 1% polidocanol or 1% polidocanol foam, and then 1 mL of 3% polidocanol or 3% polidocanol foam was injected into the greater saphenous vein under duplex guidance. Venous obstruction and recanalization were screened by serial posttreatment duplex examination, and posttreatment air plethysmography analysis was performed 3, 6, 9, and 12 months after the sclerotherapy.

RESULTS

Duplex scanning demonstrated complete occlusion in the greater saphenous vein for duplex-guided foam sclerotherapy in 25 limbs (67.6%), which was a significantly higher proportion than for the duplex-guided liquid sclerotherapy (7 limbs, 17.5%, p<0.0001). Recurrent varicose veins were found in 3 patient (8.1%) in the duplex-guided foam sclerotherapy group and 10 (25%) in the duplex-guided liquid sclerotherapy group at 1-year (p=0.048). In duplex-guided foam sclerotherapy, venous filling index values remained normal during the subsequent follow-up examinations, whereas in duplex-guided liquid sclerotherapy, venous filling index began to increase, and there was a significant difference at 6 months between duplex-guided foam sclerotherapy and the duplex-guided liquid sclerotherapy (p<0.0005). At 9 months, there was a significant difference in the residual venous fraction between the two groups, and the residual venous fraction value continued to improve in duplex-guided foam sclerotherapy (p=0.033).

CONCLUSIONS

Duplex-guided foam sclerotherapy could have greater promise compared to duplex-guided liquid sclerotherapy in the treatment of superficial venous insufficiency.

Gross anatomy of primary varicose veins observed in endoscopic surgery

The gross anatomy of varicose veins is one of the most important factors in the study of varicosity. Because of wide variations in the extent of involvement and degree of severity of varicose veins, it is difficult to obtain live and intact specimens of varicose veins. With good illumination and magnified monitor viewing, the varicositic main channel, its tributaries, and the incompetent perforating veins can be dissected and visualized clearly during endoscopic surgery. Thus, the whole range of varicosities can be observed directly in situ. Characteristic features of the varicosities of 350 limbs have been recorded by video and photographs for study and classification. These features include: 1) poor contractility of varicose veins; 2) dilated and tortuous changes of varicose veins; 3) saccular or lateral bulging deformities of vein walls, or both; 4) uniformly dilated and tortuous deformities of a long vein; 5) varicositic changes of the accessory vein; 6) anatomic abnormalities of varicose veins, such as supernumerary tributaries, varicositic clusters, and a crowded relationship among the long saphenous vein, perforating vein and tributaries; 7) various conditions of the perforating veins; and 8) the close relationship among the long saphenous vein, perforating veins, and the saphenous nerve. These data provide valuable information for the study and management of primary varicose veins.

Comparative evaluation of duplex-derived parameters in patients with chronic venous insufficiency: correlation with clinical manifestations

BACKGROUND

Quantification of venous reflux is still a matter of debate. Our goal was to compare the duplex-derived parameters between patients with early and advanced chronic venous insufficiency (CVI), and to determine indicative parameters reflecting the progression of CVI.

STUDY DESIGN

A total of 1,132 limbs in 914 patients with primary valvular incompetence were included. Clinical manifestations were categorized according to the CEAP (clinical, etiologic, anatomic, and pathophysiologic) classification, and the patients were divided into two groups: group I (those with relatively early CVI, C(1-3)E(P),A(S,D,P),P(R)) and group II (those with advanced CVI, C(4-6)E(P),A(S,D,P),P(R)). The distribution of venous insufficiency was determined, and the parameters assessed were the duration of reflux (s), the peak reflux velocity (cm/s), and the flow at peak reflux (mL/s).

RESULTS

There was no notable difference in overall superficial venous reflux between the groups, and the frequency of isolated deep and perforator incompetence did not differ between the groups. The duration of reflux did not improve the discrimination power between the groups. In contrast, the peak reflux velocity had significant discrimination power at the saphenofemoral junction (p < 0.0001), the saphenopopliteal junction (p = 0.0002), in the greater saphenous vein (p < 0.0001), in the superficial femoral vein (p = 0.0041), and in the popliteal vein (p = 0.003). The peak reflux flow was significantly higher in group II at the saphenofemoral junction (p < 0.0001), the saphenopopliteal junction (p = 0.0029), in the greater saphenous vein (p < 0.0001), in the common femoral vein (p = 0.006), in the superficial femoral vein (p = 0.0005), and in the popliteal vein (p = 0.0003).

CONCLUSIONS

Superficial venous insufficiency might play a major role in the development of advanced CVI. The peak reflux velocity and peak reflux volume improve discrimination power between early-stage and advanced CVI.

Investigation and treatment of chronic venous ulcer disease

INTRODUCTION

The investigation and treatment of chronic venous ulceration continues to present many difficulties for the clinician. The uncertainties relate to the appropriate use of different forms of investigation and whether conservative treatment or surgical treatment should be used.

METHOD

A comprehensive search was undertaken of published literature on venous ulceration.

RESULTS

The extent of investigations is largely determined by the type of treatment that the patient is either fit to undertake or is prepared to undertake. When conservative treatment only is to be used, detailed investigation of the venous system is not required. The role of surgery to the veins remains unproven in improving the healing of venous ulcers. Surgery to prevent ulcer recurrence has been demonstrated to be of benefit only in patients who have normal deep veins.

CONCLUSIONS

Investigations performed on the venous system should be determined by the planned treatment. Many of the operations that have been performed on the venous system still remain unproven in providing a benefit to the healing of venous ulcers and in preventing venous ulcer recurrence.

Quantitative assessment of superficial venous insufficiency using duplex ultrasound and air plethysmography

OBJECTIVE

The purpose of this study was to quantitatively evaluate venous reflux in limbs with isolated superficial venous insufficiency using color duplex ultrasound. In addition, air plethysmography (APG) was used to investigate possible correlations of duplex-derived peak velocity, duration of reflux, and CEAP classification.

METHODS

One hundred and forty-six legs in 109 patients with isolated superficial venous insufficiency refluxing throughout the length of the limb were selected for prospective study by duplex scan. Reflux was defined as duration of reflux >/=0. 5 seconds. This study was conducted in a university hospital. Venous reflux was evaluated with the patients standing, by the duration of reflux, retrograde peak velocity, reflux volume at the saphenofemoral and saphenopopliteal junction as well as the greater saphenous vein in the thigh. Values obtained by APG were the venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual venous fraction (RVF). A significant difference was defined as P <.05. Three groups of limbs were analyzed: group A limbs with a retrograde peak velocity greater than 30 cm/second and a duration of reflux of less than 3 seconds; group B with a retrograde peak velocity >/=30 cm/second and a duration of more than 3 seconds; and group C with a retrograde peak velocity of less than 30 cm/second and a duration of reflux of more than 3 seconds.

RESULTS

Groups A and B contained 103 limbs, and 24 of these were in CEAP class 5 and 6. Group C contained 43 limbs, none of which were in class 5 or 6. APG demonstrated significant reflux in group A, and VFI was significantly higher compared to group B and group C (P =.0007 and P =.0064, respectively). A significant correlation was demonstrated between peak retrograde reflux velocity and VFI.

CONCLUSIONS

Severe chronic venous insufficiency is found in limbs with high reflux velocity (greater than 30 cm/second) and the duration of reflux does not correlate with severe chronic insufficiency.

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.

Duplex ultrasound in the pre-operative assessment of varicose veins

A technique for the pre-operative localization of sites of incompetence using B mode and Doppler ultrasound (duplex) is described. The reliability of this investigation was compared with the clinical assessment of a group of surgeons experienced in varicose vein surgery, and with the subsequent surgical findings. Duplex scans were found to be over 98% sensitive and 93-97% specific compared with the surgical findings. Clinical techniques were much less sensitive and specific, and in addition there was uncertainty about incompetence in up to 52% of cases. The place of ultrasound and comparison with other techniques is discussed. While this technique is widely used, especially in vascular laboratories, the technique has not previously been reported in detail.

Ambulatory strain-gauge plethysmography and blood volume scintimetry for quantitative assessment of venous insufficiency

In the present study, a strain-guage plethysmographic method (ASGP) is compared to an isotope plethysmographic method (ABVS), in order to evaluate how an externally recorded volume change corresponds to blood displacement within the leg during exercise. The coefficient of correlation for RT (venous return time) was 0.67 (P less than 0.001) and for EV (expelled volume) it was 0.61 (P less than 0.001). The RT values were similar by the two methods both in healthy controls and in patients with Chronic Venous Insufficiency (CVI). The corresponding EV values showed the same pattern in controls and patients but the values differed substantially. By ASGP the value was approximately 2 ml per 100 ml tissue compared to 33 ml per 100 ml blood by the ABVS method. Both methods could clearly distinguish normal controls from patients with chronic deep venous insufficiency, but ABVS could only make this distinction when the ankle area of measurement was applied.

An evaluation of Doppler ultrasound and photoplethysmography in the investigation of venous insufficiency

Non-invasive methods of venous assessment have been developed to improve diagnostic accuracy in the assessment of venous insufficiency. Of these, continuous wave Doppler (CWD) ultrasound and photoplethysmography are the cheapest and most simple to perform. In this study duplex scanning was used to test the accuracy of these two methods. One hundred and thirty-six patients attending the venous outpatient clinic at Middlesex Hospital, London were examined by all three techniques and a diagnosis was reached using each technique. The technicians performing the examinations were unaware of the diagnoses reached by the other methods. Continuous wave Doppler ultrasound was found to be most accurate in the diagnosis of long saphenous incompetence (sensitivity 73%, specificity 85%). Due to the variability of venous anatomy at the popliteal fossa and the 'blindness' of the technique, it was inaccurate in the diagnosis of short saphenous incompetence (sensitivity 33%) and deep vein reflux (sensitivity 48%). Photoplethysmography was found to be most accurate in the diagnosis of deep vein reflux (sensitivity 79%, specificity 70%) but was inaccurate in identification of the site of superficial vein reflux. Inaccuracies may be attributed to the presence of incompetent perforating veins and variation in arterial inflow.