Patterns of venous insufficiency in patients with varicose veins

Red vine leaf extract (AS 195) can improve some signs and symptoms of chronic venous insufficiency, a systematic review

AIM

Chronic venous insufficiency (CVI) is common in adults. Some complications include skin changes, edema, heavy legs, muscle cramps, pain, and varicose veins. In traditional medicine, red vine leaf extract (AS 195) has been used to cure the symptoms of CVI. This systematic review was aimed to assess the effects of AS 195 in patients with CVI.

MATERIAL AND METHODS

A systematic literature search was performed to identify trials that reported the impact of red vine leaf extract on CVI. The primary outcomes investigated were Leg (limb) volume, calf circumference, ankle circumference, tired and heavy legs, a sensation of tension, tingling sensation, and pain.

RESULTS

From the 56 studies, 5 trials were selected according to our inclusion criteria. Red vine leaf extract significantly improved numbers of outcomes (lower leg volume, calf and ankle circumference, tired, heavy legs, tingling sensation, pain, the sensation of tension in the legs, cutaneous microcirculation, and transcutaneous oxygen pressure) in only some trials. The tolerability for red vine leaf extract was reported good or satisfactory.

CONCLUSIONS

Red vine leaf extract had a beneficial therapeutic role in patients with CVI. Further high-quality trials are required to be carried out to provide strong evidence.

Autogenously derived regenerative cell therapy for venous leg ulcers. ACTA ACUST UNITED AC. 2018;3:e156-e163. [PMID: 30775606 PMCID: PMC6374579 DOI: 10.5114/amsad.2018.81000]

Introduction

Venous leg ulcers (VLUs), which arise from chronic venous insufficiency in the lower limbs, are a major cause of morbidity and significantly negatively impact patients’ health-related quality of life. Treatment of venous ulcers can be either conservative or surgical. Despite appropriate treatment, VLUs can be resistant to healing. Clinical results of treatment of venous foot ulcers with adipose-derived autologous stem cells, which did not improve despite the surgical treatment of the underlying venous pathology in the following case series, are reported.

Material and methods

Between April 2015 and January 2016, a total of 31 patients who had undergone surgery for underlying venous pathology but the venous ulcer had not healed were included in the study. The mean venous ulcer size was 3.6–6.2 cm (range: 2 to 8 cm by 3 to 9 cm). All patients were treated with adipose-derived autologous stem cells prepared using the MyStem Regenerative Adipose-Derived Stem Cell Purification Kit (MyStem LLC, USA). The ulcer diameter was measured and recorded in the third, sixth and twelfth months. The follow-up time was 12 months after ulcer healing.

Results

Eighteen ulcers demonstrated complete healing at the 12^th month. Thirteen ulcers exhibited serious contraction and epithelialization even though the ulcer was not completely closed. At the 12^th month, the ulcer size was reduced by 96.00 ±1.74% in these patients. The reduction in the ulcer area based on the month analyzed was significant (p = 0.001; p < 0.01). After the ulcers healed, the patients were followed for recurrence for one year. Recurrent ulcers were observed at the treated sites in 3 of 31 patients (9%). No adverse events, such as infection, inflammation, or tissue reactions, were observed.

Conclusions

Application of cell therapy in venous leg ulcer is currently used exclusively in patients not responding to the standard treatment. Autogenously derived regenerative cell therapy for VLUs can be considered as an additional treatment to primary surgical therapy.

Long-Term Recurrence and Nerve Injury After Total and Partial Stripping of the Great Saphenous Vein by External Phleboextractor

The objective of this study was to assess the efficacy of an external phleboextractor (EP) in improving the results of total and short stripping of the great saphenous vein (GSV) with particular reference to saphenous nerve injury occurring during the operations. Two hundred fifty-seven consecutive patients affected by varicose veins in the lower limbs (of which 22 had bilateral diseases) underwent total (Group A) or partial (Group B) saphenectomies by means of the Corcos' EP. The interventions were selected on the basis of type of reflux diagnosed by clinical and Doppler ultrasound examinations. The results were assessed 6 months and 3 years after operation. One hundred four limbs were evaluated in Group A and 160 limbs in Group B. After 3 years, 101 limbs in Group A (97.1%) and 155 in Group B (96.8%) had excellent-to-good results in terms of recurrent varices. Neurological examinations were comparable between Group A (11 saphenous nerve injuries = 10.6%) and Group B (10 nerve injuries = 6.3%). This study shows that total or short stripping of the GSV reduced varicose vein recurrence and neural compli cation using the EP.

Venoscopy in Varicose Vein Surgery: Initial Experience

Objective:

To determine the number and function of valves and the location of perforators and tributaries in patients with varicose veins as a result of saphenofemoral or saphenopopliteal reflux.

Design:

Prospective endovascular evaluation of greater and lesser saphenous veins during varicose vein surgery.

Setting:

Cedars-Sinai Medical Center, Los Angeles, California, USA.

Patients:

Thirty-one limbs in 25 patients undergoing varicose vein surgery.

Intervention:

Patients underwent retrograde passage of a 2.3 mm angioscope from the junction of the saphenous and deep vein distally to the first competent valve.

Main outcome measures:

Based on intraoperative findings, the greater saphenous vein was preserved in eight out of 25 cases. Preoperative assessment of lesser saphenous reflux was incorrect in three out of six cases.

Results:

An incompetent subterminal valve was found in 16 out of 25 greater saphenous veins. In 13 out of 25 limbs, no other valves were seen to the knee. Four patients had competent thigh valves.

Conclusions:

Retrograde venoscopy may be of benefit in varicose vein surgery.

Recurrent Varicose Veins and Primary Deep Venous Insufficiency: Relationship and Therapeutic Implications

Objective:

Evaluation of the relationship between deep venous insufficiency and recurrent varicose veins (RVV).

Design:

Retrospective analysis of patients affected by RVV submitted to clinical examination, continuous-wave (CW) Doppler, duplex scanning and descending phlebography in cases of incompetence at groin level.

Setting:

Department of Vascular Surgery, Istituto Dermopatico dell'Immacolata (IRCCS), Rome.

Patients:

Two hundred and thirty-nine patients affected by RVV.

Main outcome measures:

CW Doppler ultrasound, duplex ultrasound imaging and descending phlebography to assess venous incompetence.

Results:

Doppler examination revealed no reflux at the groin level in 80 limbs. In the remaining 166 limbs, descending phlebography showed a superficial venous reflux in 95 limbs (related to a sapheno-femoral junction recanalization or to an inadequate previous operation) while in 69 (28% of the 246 limbs examined) deep venous reflux was present (superficial femoral vein in 38 cases, profunda femoris vein in seven cases and both veins in 24 cases); in two cases reflux came from the pelvic veins.

Conclusions:

Our data suggest a possible role of primary deep venous insufficiency in the development of RVV and the value of descending phlebography in the planning of further surgery.

Anatomical Patterns in Varicose Vein Disease: A Duplex Scanning Study

Objectives:

To determine symptomatology, clinical class, and topographic patterns of varicose veins in a consecutive series of patients with venous complaints.

Methods:

We performed clinical examination and duplex scanning of 498 lower limbs in 317 patients with obvious varicose veins for whom no previous treatment had been undertaken.

Results:

Classes of chronic venous insufficiency (CVI) in 498 legs: grade 0: 117 (23.5%); gr 1: 310 (62.2%); gr 2: 47 (9.4%); gr 3: 24 (4.8%). Duplex-detected venous reflux was found in the greater saphenous vein territory (junction or trunk or related perforator or main tributary) in 423 limbs (85.3%) the sapheno-femoral junction was incompetent in only 342 legs (68.7%). Reflux was found in the lesser saphenous vein territory in 100 limbs (20.1%) and in sapheno-popliteal junction in 92 (18.5%). Strictly non saphenous origin of varicosities was found in 31 limbs (6.2%). Deep venous incompetence was found in 48 legs (9.6%).

Conclusions:

These findings yield data on the distribution and occurence of lower limbs venous lesions in patients with varicose disease.

Venous Reflux at the Sapheno-Femoral Junction

Objectives:

To clarify reflux patterns in the sapheno-femoral junction in legs with varicose veins that display incompetence in the proximal long saphenous vein on duplex scan examination.

Patients and method:

One hundred consecutive extremities were selected for ultrasound studies. Venous reflux was examined in the common femoral vein and long saphenous vein at five selected levels in the vicinity of the sapheno-femoral junction.

Results:

Duplex ultrasound examination confirmed that in 44 extremities reflux was detectable both in the long saphenous vein and common femoral vein indicating ‘true’ sapheno-femoral incompetence. In 56 legs reflux was limited to the long saphenous vein, whilst the first saphenous valve remained competent. The ultrasound examination suggested that in these cases the reflux originated from the numerous tributaries of the proximal long saphenous vein.

Conclusion:

Our findings emphasize the transfascial escape (reflux from the deep veins) is not a necessary precondition of long saphenous vein incompetence and related varicose veins.

Reproducibility of Duplex Ultrasound in the Measurement of Venous Reflux

Objective:

To determine the reproducibility of duplex ultrasound in the measurement of reflux duration in lower limb veins.

Design:

Repeatability study.

Setting:

Vascular clinic in a tertiary referral centre.

Participants:

Twenty-one patients with severe venous disease.

Interventions:

Patients were scanned using duplex ultrasound by two of three observers, then rescanned by a different pair of observers after a mean interval of 51 days.

Main outcome measures:

Duration of venous reflux.

Results:

On a Wilcoxon signed rank test, observers 2 and 3 showed no significant interobserver variability. The other pairs of observers agreed at the majority of segments, but differed at the popliteal vein ( p≤0.001), and superficial femoral and common femoral veins ( p≤0.05). Observer 2 showed no significant intraobserver variability, but observer 1 differed at the common femoral and superficial femoral veins ( p≤0.05), and observer 3 differed at the short saphenous vein ( p≤0.05).

Conclusions:

Reproducibility was reasonable at certain sites, but appeared to be influenced by position of the vein.

Changes in the diameter and valve closure time of leg veins in primigravida women during pregnancy

OBJECTIVE

The aim of this study was to monitor the changes that develop in leg veins of primigravida women during pregnancy.

METHODS

Sixty primigravida women volunteered to undergo clinical evaluation and duplex ultrasound examination of both lower limb veins to monitor changes in vein diameter and valve closure time (VCT) during pregnancy and 3 months postpartum by duplex ultrasound. A total of four readings were taken for each subject, one reading for each trimester and the last reading at 3 months postpartum.

RESULTS

The mean (± standard deviation) age of participants was 26.82 ± 2.47 years; 39 limbs (32.5%) and 65 limbs (54.2%) developed C1-C3 venous changes during the second and third trimesters, respectively. Three months post partum, 36 limbs (30%) continued to have C1-C2 changes. Only four limbs in four subjects developed varicose veins along the great saphenous vein, and their VCT was more than 1 second. These subjects were found to have a family history of varicose veins. Duplex examinations showed that there was a gradual increase in the diameter and VCT from the second trimester through the third trimester of pregnancy in all examined venous segments. These changes were statistically significant by Friedman and related-samples Wilcoxon signed rank tests within the same legs (P = .001) but not between legs in the same subject (P > .05), even with adjustment for body mass index (P = .001-.049).

CONCLUSIONS

In primigravida women, lower limb veins showed gradual increase in vein diameter and in VCT starting from the second trimester. These changes reverted to baseline in most cases 3 months after delivery.

A study to evaluate patterns of superficial venous reflux in patients with primary chronic venous disease

Objective

This study assessed patterns of superficial reflux in patients with primary chronic venous disease.

Methods

Retrospective review of all patient venous duplex ultrasonography reports at one institution between 2000 and 2009. Legs with secondary, deep or no superficial reflux were excluded.

Results

In total, 8654 limbs were scanned; 2559 legs from 2053 patients (mean age 52.3 years) were included for analysis. Great saphenous vein reflux predominated (68%), followed by combined great saphenous vein/small saphenous vein reflux (20%) and small saphenous vein reflux (7%). The majority of legs with competent saphenofemoral junction had below-knee great saphenous vein reflux (53%); incompetent saphenofemoral junction was associated with combined above and below-knee great saphenous vein reflux (72%). Isolated small saphenous vein reflux was associated with saphenopopliteal junction incompetence (61%), although the majority of all small saphenous vein reflux limbs had a competent saphenopopliteal junction (57%).

Conclusion

Superficial venous reflux does not necessarily originate from a saphenous junction. Large prospective studies with interval duplex ultrasonography are required to unravel the natural history of primary chronic venous disease.

Changes in the diameter and valve closure time of leg veins across the menstrual cycle

OBJECTIVES

The purpose of this study was to determine the changes (if any) in the diameter and valve closure time of the lower limb veins in healthy young nulliparous women at different phases of the menstrual cycle.

METHODS

Fifty-three young nulliparous women were asked to undergo clinical evaluations and duplex ultrasound examinations of both lower limb veins to monitor changes in the vein diameter and valve closure time at different phases of their menstrual cycles. The vein diameter on B-mode imaging and valve closure time on pulsed Doppler tracing were calculated at days 1 to 4, 14 to 16, and 25 to 28 of the menstrual cycle. Freidman and related samples Wilcoxon signed rank tests were used to determine time-related changes in venous function.

RESULTS

The volunteers' mean age ± SD was 20.60 ± 1.90 years, and their mean body mass index was 23.90 ± 4.90 kg/m(2). There was a gradual increase in the vein diameter and valve closure time at the specified phases of the menstrual cycle. Friedman and related samples Wilcoxon signed rank tests for venous segment diameter and valve closure time changes between the different phases of the menstrual cycle were performed and showed statistical significance for each venous segment within each limb (P = .003-.025). Also, when adjusted for body mass index, statistical significance existed for the same venous segments in the same limbs (P =.001-.049). There was no statistical significance for the same venous segments at the same phase of the menstrual cycle between limbs (related samples Wilcoxon signed rank test: P =.079-.97).

CONCLUSIONS

During the menstrual cycle, the lower limb veins show an increase in their diameter and valve closure time. These changes are probably mediated by the female sex hormones.

Patterns of short saphenous vein incompetence

The significance of short saphenous vein (SSV) reflux is an under-explored territory in chronic venous disease (CVD). We have examined the origin and significance of SSV reflux in primary and secondary CVD. While the natural history of SSV incompetence remains uncertain, its prevalence has been shown to approximate 3.5%, rising with progressing clinical venous insufficiency, and bears an association with lateral malleolar venous ulceration. The most common pattern of reflux extends throughout the SSV Patterns of incompetence in recurrent disease are highly variable, but SSV reflux may itself pose a risk for recurrence, in part due to the complex anatomy of the saphenopopliteal system. Further studies are required to delineate the impact of SSV reflux in secondary venous disease and deep venous incompetence.

An overview of the surgical aspects of lower limb venous disease

Lower limb venous disease encompasses a wide spectrum of pathology, the importance of which relates to high prevalence rather than mortality. The complications of chronic venous insufficiency (CVI), namely lipodermatosclerosis and chronic venous ulceration, represent a major burden to healthcare providers and a high degree of personal morbidity for patients. Management is based upon accurate clinical diagnosis supported by non-invasive imaging. Open surgical and minimally invasive techniques are used to treat varicose veins. Chronic skin complications of CVI require a multidisciplinary approach.

Preservação da veia safena magna na cirurgia de varizes dos membros inferiores

A veia safena magna autóloga é o melhor substituto arterial nas revascularizações dos membros inferiores, importante na revascularização do miocárdio e pode ser utilizada nas cirurgias do sistema venoso e nos traumas das extremidades. A fleboextração aumenta os riscos de lesões linfáticas e neurológicas. Assim, no tratamento das varizes primárias dos membros inferiores por meio da cirurgia ou de outras técnicas, a preservação da safena é recomendável se ela for normal ou apresentar alterações que ainda permitam sua preservação pela correção da causa desencadeante. Tal correção pode ser feita por técnicas cirúrgicas. Entre elas, a cura hemodinâmica da insuficiência venosa em ambulatório (CHIVA) tem mostrado bons resultados. Recentemente, um ensaio clínico randomizado e controlado foi publicado comprovando sua eficácia. Outra técnica bastante utilizada é a da ligadura rasante da junção safenofemoral + crossectomia + ligadura das tributárias de crossa, com a qual se tem obtido resultados contraditórios. Finalmente, as técnicas que corrigem a insuficiência da safena reparando as valvas ostial e pré-ostial (valvoplastia externa) são mais fisiológicas. Um ensaio clínico internacional multicêntrico, randomizado e controlado, testando um novo dispositivo, está sendo realizado, com resultados iniciais favoráveis. Este estudo pretende fazer uma revisão sobre as técnicas utilizadas na preservação da safena magna.

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.

Clinical Significance of Ostial Great Saphenous Vein Reflux

PURPOSE

To evaluate anatomical and haemodynamic differences in patients with great saphenous vein (GSV) insufficiency by duplex scanning and air plethysmography.

MATERIAL AND METHODS

Duplex scanning and air plethysmography examination were undertaken. One hundred and twenty-one limbs in 91 patients were selected prospectively and divided into three groups: group A consisted of 27 controls; group B consisted of 25 limbs with GSV reflux and normal saphenous femoral junction (SFJ) and group C consisted of 69 limbs of patients with GSV and SFJ reflux. The presence of reflux and GSV diameter (SFJ, proximal and medial thirds of the thigh, the knee and medial and distal thirds of the calf) were assessed by duplex scanning. Air plethysmography was used to evaluate haemodynamic parameters: total venous volume (VV), venous filling index (VFI), residual volume fraction (RVF) and ejection fraction (EF).

RESULTS

There was a significant difference in GSV diameter among the three groups in almost all segments evaluated (e.g. medial thigh group A = 2.4 SD 0.3 mm; B = 3.2 SD 0.7 mm; C = 5.9 SD 2.2mm p<0.001, Anova). A significant difference in VFI was found among the groups (group A = 1.2 SD 0.5; B = 2.0 SD 1.4; C = 4.0 SD 2.5 p<0.05, Anova). VV was statistical different between groups A and C (p = 0.004) and B and C(p = 0.03). EF and RVF were comparable in all groups. The VFI was normal in 68% in group B comparing with only 14.5% in group C patients, finding a reflux more than 5ml/s (determined by VFI) in 26.1% of the group C patients, comparing with only 4% of group B patients (p<0.05).

CONCLUSION

We have shown that in patients with GSV reflux those with incompetence of the ostial valve of the GSV show greater venous reflux and dilatation of the saphenous trunk than those in whom the ostial valve is competent.

Patient characteristics and physician-determined variables affecting saphenofemoral reflux recurrence after ligation and stripping of the great saphenous vein

OBJECTIVE

To identify patient and physician-controlled treatment variables that might predict the persistence or redevelopment of saphenofemoral junction (SFJ) reflux.

METHODS

Thirteen European centers, with substantial lower extremity venous disease practices, examined their experience with SFJ ligation and GSV stripping for primary varicose veins in patients followed for > or =2 years, entering their data into a protocol-driven matrix that stipulated duplex Doppler imaging as an essential component of follow-up examinations and required a complete review of all peri-operative examinations, as well as all operative procedure and anesthesia notes. Matrix entries were centrally audited for consistency and credibility, and queried for correction or clarification before being accepted into the study database. Presence or absence of Doppler-detectable SFJ reflux was the dependent variable and principal outcome measure.

RESULTS

Among 1,638 limbs, 315 (19.2%) had SFJ reflux. After adjustment for follow-up length and inputting for missing values, multivariable analysis identified seven significant predictors. Ultrasonic groin mapping (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.20 to 0.40) and <3-cm groin incisions at or immediately below the groin crease (OR, 0.50; 95% CI, 0.32 to 0.78) were both uniquely associated with diminished probability of follow-up SFJ reflux. Prior parity (OR, 2.69; 95% CI, 1.45 to 4.97), body mass index >29 kg/m(2) (OR, 1.65; 95% CI, 1.12 to 2.43), <3-cm suprainguinal incisions (OR, 3.71; 95% CI, 1.70 to 5.88), stripping to the ankle (OR, 2.43; 95% CI, 1.71 to 3.46), and interim pregnancy during follow-up (OR, 4.74; 95% CI, 2.47 to 9.12), were each independent predictors of a greater probability of having SFJ reflux.

CONCLUSIONS

The findings suggest that ultrasound groin mapping, reticence for short suprainguinal or longer groin incisions and extended stripping, and counseling women about the effect of future pregnancy are prudent clinical choices, especially for obese or previously parous patients.

Randomised trial of pre-operative colour duplex marking in primary varicose vein surgery: outcome is not improved

OBJECTIVE

the ability of colour duplex to accurately locate incompetent venous sites has been widely published; its value in pre-operative marking in simple primary varicose vein surgery is evaluated in this study.

DESIGN OF STUDY

prospective randomised controlled trial.

SETTING

regional vascular service, hospital patients.

SUBJECTS

consecutive patients (149) undergoing primary varicose vein surgery where the only difference was one group of patients received duplex marking prior to surgery. Six weeks and 12 months post-operatively all patients had a colour duplex scan to determine the accuracy of surgery and the presence of residual/recurrent varicose veins and completed the Aberdeen, SF-36, and EuroQol quality of life questionnaires.

INTERVENTIONS

varicose vein surgery.

MAIN OUTCOME MEASURES

Duplex evidence of venous incompetence, quality of life measures using the SF-36 and Aberdeen Varicose Veins Questionnaire.

RESULTS

pre-operative marking of primary varicose veins by skilled duplex ultrasonography does not improve the accuracy or recurrence rate following surgery. Quality of life improved significantly following surgery in both groups, however there was no difference in this improvement between the groups.

CONCLUSION

the trial has not demonstrated any additional benefit of pre-operative colour duplex marking over that of clinical and hand held Doppler marking in terms of satisfactory varicose vein surgery performance at 6 weeks or 12 months in patients with primary varicose veins of the long saphenous system. It role in the short saphenous system is less clear.

Investigation of Venous Disease

Aim:

To review the investigations which are performed in patients presenting with varicose veins prior to treatment.

Method:

A review of current literature in the field of the investigation of venous disease of the lower limb has been conducted using MedLine.

Synthesis:

Continuous wave (CW) Doppler is effective in detecting venous reflux in the sapheno-femoral junction and the long saphenous vein. In the popliteal fossa, for perforating veins and for the deep veins this technique has reduced accuracy. Duplex ultrasonography is widely used in the management of venous disease of the lower limb. This investigation provides reliable anatomical information but limited functional data about the veins. Phlebography and varicography are effective investigations but are being replaced by duplex ultrasonography. Plethysmographic tests assess venous function but are poor at anatomical identification of the problem. They may be used in the monitoring of venous function during treatment and in identifying the contribution of superficial venous reflux in patients with combined deep and superficial venous disease.

Conclusion:

Clinical examination is no longer sufficient to assess patients with venous disease of the lower limb prior to surgery. CW Doppler is the minimum investigation but duplex ultrasonography is the most effective non-invasive investigation. Plethysmographic tests have limited application in the management of varicose veins.

Deep venous thrombosis and superficial venous reflux

OBJECTIVE

Although superficial venous reflux is an important determinant of post-thrombotic skin changes, the origin of this reflux is unknown. The purpose of this study was to evaluate the frequency and etiologic mechanisms of superficial venous reflux after acute deep venous thrombosis (DVT).

METHODS

Patients with a documented acute lower extremity DVT were asked to return for serial venous duplex ultrasound examinations at 1 day, 1 week, 1 month, every 3 months for the first year, and every year thereafter. Reflux in the greater saphenous vein (GSV) and lesser saphenous vein (LSV) was assessed by standing distal pneumatic cuff deflation.

RESULTS

Sixty-six patients with a DVT in 69 lower extremities were followed up for a mean of 48 (SD +/- 32) months. Initial thrombosis of the GSV was noted in 15 limbs (21.7%). At 8 years, the cumulative incidence of GSV reflux was 77.1% (SE +/- 0.11) in DVT limbs with GSV involvement, 28.9% (+/- 0.09%) in DVT limbs without GSV thrombosis, and 14.8% (+/- 0.05) in uninvolved contralateral limbs (P <.0001). For LSV reflux, the cumulative incidence in DVT limbs was 23.1% (+/- 0.06%) in comparison with 10% (+/- 0.06%) in uninvolved limbs (P =.06). In comparison with uninvolved contralateral limbs, the relative risk of GSV reflux for DVT limbs with and without GSV thrombosis was 8.7 (P <.001) and 1.4 (P =.5), respectively. The relative risk of LSV reflux in thrombosed extremities compared with uninvolved extremities was 3.2 (P =.07). Despite these observations, the fraction of observed GSV reflux that could be attributable to superficial thrombosis was only 49%.

CONCLUSIONS

Superficial venous thrombosis frequently accompanies DVT and is associated with development of superficial reflux in most limbs. However, a substantial proportion of observed reflux is not directly associated with thrombosis and develops at a rate equivalent to that in uninvolved limbs.

Programmed cell death (Apoptosis) and its role in the pathogenesis of lower extremity varicose veins

The etiology of varicose veins remains elusive. We hypothesized that abnormal cell cycle events in the vein wall may contribute to changes in its structural integrity predisposing to varicosity development. Since cell cycle checkpoint controls are linked to the signaling and execution of apoptotic cascades, possibly apoptosis is a contributing factor in the pathophysiology of varicosities. The present study was designed to investigate whether programmed cell death varies in varicosities as compared to normal veins. Twenty-seven normal greater saphenous vein specimens were obtained from patients undergoing infrainguinal arterial bypass surgery, and 20 varicose vein specimens were retrieved from patients undergoing varicose vein excision. Apoptosis was detected by TUNEL assay. Expression of bcl-2 and cyclin D1 was noted by standard immunohistochemical techniques. Apoptotic cells were identified in 32 of the 47 specimens. Forty-eight percent of normal vein specimens displayed >3 apoptotic cells per 100 cells in the adventitia; 15% of the specimens of the varicose vein group showed such magnitude of apoptosis (p < 0.03). This increased apoptotic activity was not observed in media or intima of either vein group (p < 0.001). No significant difference in immunoreactivity to bcl-2 protein was observed in varicose vein specimens as compared to controls. Varicose vein specimens demonstrated increased nuclear expression of cyclin D1 whereas its cytoplasmic expression was significantly diminished (p </=0.02). These data show that programmed cell death is inhibited in varicose veins. Differential expression of cyclin D1 suggests that it may deregulate cell cycle events, thereby leading to varicosity formation.

Preoperative duplex imaging is required before all operations for primary varicose veins

BACKGROUND

Physical examination is unreliable in the detection of sources of reflux in varicose veins. Hand-held Doppler (HHD) ultrasonography has been recommended as an accurate adjunct to physical examination. The aim of this study was to evaluate the accuracy of HHD imaging in comparison with duplex ultrasonography.

METHODS

Eighty-nine legs in 61 patients with primary varicose veins were examined with an HHD probe to detect reflux at the saphenofemoral junction (SFJ), the saphenopopliteal junction (SPJ) and in thigh perforators (TPs). Patients then underwent duplex imaging and the results of the tests were compared.

RESULTS

The sensitivity of the HHD technique was 73 per cent at the SFJ, 77 per cent at the SPJ and 51 per cent for TPs. In primary varicose veins the surgery planned using HHD imaging alone would have left residual sites of reflux in 24 per cent.

CONCLUSION

Examination with HHD ultrasonography is not sufficiently accurate to plan varicose vein surgery. Duplex imaging is recommended before all operations for primary varicose veins.

Tissue inhibitor of metalloproteinase-1 is increased in the saphenofemoral junction of patients with varices in the leg

PURPOSE

The goal of the present study was to examine the role of matrix metalloproteinase (MMP) activity in the development of varicose changes in the superficial veins of the lower extremity.

METHODS

Normal-caliber vein segments from the saphenofemoral junction were harvested from patients undergoing saphenous vein ligation for varices and from patients undergoing infrainguinal bypass graft procedures. The activity and quantity of MMPs and their inhibitors (tissue inhibitors of metalloproteinases [TIMPs]) in the vein segments were compared. Vein segments were obtained from 13 patients. Seven patients had varicose disease in the leg, including 6 women and 1 man (average age, 48 years). Six patients had no evidence of varicose disease, including 2 women and 4 men (average age, 59 years). Proteolytic activity was determined with substrate gel zymography, and enzyme content was determined with Western immunoblotting using monoclonal antibodies directed against MMP-2, MMP-3, MMP-9, TIMP-1, TIMP-2, and alpha2-macroglobulin. Signals were quantified by scanning densitometry and normalized to a positive control (densitometric index [DI]). Immunohistochemistry was performed for enzyme localization.

RESULTS

Zymography did not detect a difference between groups at loci consistent with the major MMPs; however, a small but significant decrease in proteolytic activity was noted in veins from patients with varices. TIMP-1 is increased in vein segments from patients with varices (DI 0.8 +/- 0.1 vs 0.2 +/- 0.05, P < .05) while MMP-2 levels were decreased (DI 1.5 +/- 0.3 vs 0.5 +/- 0.1, P < .05). Immunohistochemistry localized MMPs to the adventitia of the vein wall.

CONCLUSION

A decrease in proteolytic activity may be responsible for the histological and structural alterations leading to varicose degeneration of superficial lower extremity veins.

Correlation of the anatomical distribution of venous reflux with clinical symptoms and venous haemodynamics in primary varicose veins

AIM

The aim of this study was to correlate the anatomical distribution of venous reflux with clinical symptoms and venous haemodynamics in patients with primary varicose veins.

METHODS

Venous reflux was examined using duplex colour Doppler ultrasonography in 266 legs in 191 patients. The venous refilling and reflux times were also measured.

RESULTS

Of the 266 legs, 82 per cent had reflux in the long saphenous vein (LSV), 26 per cent in the short saphenous vein (SSV), 62 per cent had incompetent perforators (IPs) in the calf and 48 per cent had reflux in the deep veins. LSV reflux combined with SSV reflux and/or IPs was associated significantly with severe venous disease and abnormal venous haemodynamics. Femoropopliteal reflux played a role in the development of venous eczema and ulcers when combined with superficial venous reflux.

CONCLUSION

Patients at high risk of developing complications of venous disease may be identified by an accurate non-invasive evaluation of reflux patterns.

Popliteal vein reflux reduces the healing of chronic venous ulcer

BACKGROUND

The relationship between deep and superficial venous reflux and healing of venous ulceration by non-operative compression therapy has not been studied previously.

METHODS

A total of 155 patients with chronic venous ulcers underwent duplex ultrasonography before treatment with compression bandaging at a hospital-based venous clinic.

RESULTS

At 24 weeks, 104 (67 per cent) of ulcers had healed. There was no significant difference in the pattern of either deep or superficial venous reflux between healed and non-healed ulcers except with respect to the popliteal vein. In healed ulcers, 39 scans (38 per cent) indicated competence of the above-knee popliteal vein compared with five (10 per cent) in the non-healing group (P < 0.001, chi 2 test). Similarly, 43 scans (42 per cent) showed below-knee popliteal vein competence in the healed ulcers compared with only five (10 per cent) performed in legs remaining ulcerated (P < 0.001, chi 2 test).

CONCLUSION

Popliteal vein incompetence is an indicator of poor response to compression therapy for venous ulceration.

Hemodynamic assessment of femoropopliteal venous reflux in patients with primary varicose veins

PURPOSE

The aim of this study was to assess the anatomic distribution and extent of deep venous reflux in patients with primary varicose veins (PVVs) and to investigate its influence on venous hemodynamics.

METHODS

Femoropopliteal venous reflux was examined using duplex color Doppler ultrasonography in 356 limbs with PVVs in 240 patients. Photoplethysmography (PPG) was performed using above-knee and below-knee tourniquets to determine the contributions of deep and superficial venous insufficiency.

RESULTS

Of 356 limbs with PVVs, 61 (17.1%) had femoropopliteal venous reflux, 42 (11.8%) had superficial femoral venous reflux alone, and 57 (16.0%) had popliteal venous reflux alone. Femoropopliteal venous reflux was associated significantly with clinical symptoms and shortened the half venous refilling time measured by PPG, especially in the presence of incompetent perforating veins. These findings were obtained regardless of the presence of long saphenous vein reflux.

CONCLUSIONS

Femoropopliteal venous reflux associated with PVVs plays an important role in the pathophysiologic mechanism of venous stasis and influences venous hemodynamics in the presence of incompetent perforating veins and short saphenous vein.

Validation of duplex ultrasonography in detecting competent and incompetent perforating veins in patients with venous ulceration of the lower leg

PURPOSE

Incompetent perforating veins play an important role in the etiologic mechanism of venous ulceration and recurrent varicose veins. The anatomic and functional status of the venous system can be evaluated by duplex ultrasonography. To determine the value of this technique in the identification of competent and incompetent perforating veins, a prospective study was performed.

METHODS

In patients who underwent subfascial exploration for venous ulceration of the lower leg, the preoperative findings of duplex ultrasonography were compared with the findings at surgical exploration.

RESULTS

In 20 consecutive patients, 42 incompetent and 8 competent perforating veins were detected by duplex ultrasonography. During operation the location of all 50 perforating veins appeared to be predicted correctly. Eleven additional perforating veins that had not been detected by duplex ultrasonography were found during operation. The sensitivity and specificity of duplex ultrasonography in predicting the site of perforating veins at the medial side of the lower leg in our study were 79.2% and 100%, respectively, for incompetent perforating veins and 82% and 100%, respectively, for competent and incompetent perforating veins.

CONCLUSION

These figures indicate that duplex-guided local exploration of the lower leg in patients with venous ulceration as a result of incompetent perforating veins would miss a substantial number of perforating veins, possibly leading to incomplete healing or recurrent ulceration.

Comparison between clinical examination, cw-Doppler ultrasound and colour-duplex sonography in the diagnosis of incompetent perforating veins

OBJECTIVES

This study was conducted to investigate the accuracy and agreement between clinical examination, continuous wave (cw)-Doppler ultrasound and colour-duplex sonography (CDS) in diagnosing incompetent perforating veins (ICPV).

DESIGN

Observational cohort study.

MATERIAL AND METHODS

Nineteen patients with chronic venous insufficiency (CVI) were examined clinically, by hand-held cw-Doppler ultrasound in combination with tourniquet compression and CDS.

RESULTS

The low accuracy of the clinical examination and the diagnosis of ICPV by cw-Doppler were surprising. The specificity was 15% and sensitivity 29%, when CDS was taken as the "gold standard". Furthermore the results show clearly that the application of a tourniquet cannot provide reliable results.

CONCLUSIONS

In patients with CVI, clinical and cw-Doppler cannot accurately diagnose ICPV when compared to CDS.

The crochet hook method of stab avulsion phlebectomy for varicose veins

Excision of varicose veins through ministab incisions is currently the choice for the removal of varicose vein clusters. The crochet hook technique of stab avulsion phlebectomy is described in this paper. This surgical method for the treatment of varicose veins has been widely utilized in a residency training environment during the last twelve years and has been used by the senior author for more than 20 years. The technique is easily mastered, cost effective, and has excellent therapeutic and cosmetic results.

Duplex examination

BACKGROUND

Accurate venous diagnosis remains a challenge for the phlebologist and vascular laboratory. In recent years duplex ultrasound has become the preferred method of diagnosis for deep venous thrombosis and deep and superficial venous insufficiency.

OBJECTIVE

To describe the physical principles, typical protocol, and indications for venous duplex examination.

CONCLUSION

Duplex examination offers a precise, noninvasive technique to make anatomic and functional venous diagnoses.

Anatomy of the superficial venous system

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The nature of lower extremity venous insufficiency in patients with primary varicose veins

The purpose of this study was to investigate the distribution of vein incompetence and the nature of venous haemodynamics accompanying the development of lower extremity primary varicose veins (LEPVV). The entire venous circulation of 77 lower extremities in 55 patients (pts) with LEPVV was evaluated, by using Duplex colour Doppler ultrasonography. The greater and lesser saphenous veins (GSV, LSV) and their branches were thoroughly scanned. The valvular integrity of the deep venous system was determined in the areas of common and superficial femoral vein, saphenofemoral junction, popliteal vein, saphenopopliteal junction, and perforating veins. Demonstration of bidirectional flow signified venous incompetence. Quantitation of venous reflux was estimated after manual calf compression with pts in a standing position. All the symptomatic legs had branch venous disease, 60% had GSV incompetence, 3% had LSV incompetence, 10% showed concurrent GSV and LSV incompetence, while 27% demonstrated no evidence of GSV, and LSV disease. Thirty per cent and 50% of the symptomatic legs demonstrated deep and perforating vein incompetence, respectively. Furthermore, 30% of the asymptomatic lower extremities had insufficiency of saphenofemoral (nine pts) and saphenopopliteal (one pt) junction. The median peak venous reflux in the incompetent GSV and popliteal vein was 0.74 ml/s (range 0.2 to 2.5 ml/s) and 3.5 ml/s (range 2.5 to 8 ml/s), respectively. In conclusion, the observed heterogeneity in anatomic and functional distribution of lower extremity venous insufficiency in pts with LEPVV support the hypothesis that this condition is probably a part of another entity that might be called "lower extremity primary venous insufficiency" whose treatment should be highly individualised. To this end, colour Doppler imaging can help.

Clinical significance of venous reflux detected by duplex scanning

Duplex scanning was used to determine the presence of valvular incompetence in the major veins of 274 legs with venous disease. Using multivariate logistic regression analysis the significance of valvular function in each vein in relation to the clinical condition of the limb was calculated. Superficial femoral, profunda femoris and short saphenous vein function did not correlate with the clinical state of the limb; common femoral, popliteal and long saphenous vein function did. A table was constructed from the statistical model such that the relative contribution made by each vein could be estimated for limbs with different patterns of venous insufficiency. This model should now be tested in a prospective study and, if validated, could be used to improve decision making in venous surgery.

Physiologic similarities between extremities with varicose veins and with chronic venous insufficiency utilizing air plethysmography

Air plethysmography (APG) was used to measure maximal venous outflow rate (MVO), a test for proximal venous obstruction; venous volume; venous filling index, an estimate of valvular incompetence; ejection fraction (EF), a test of calf-muscle pump efficiency; and residual volume fraction (RVF), an estimate of ambulatory venous pressure. MVO was lower in patients with chronic venous insufficiency (CVI) than in those with varicose veins (VV), but the difference was small (p = 0.06). RVF was significantly greater in extremities with CVI when compared with those with VV (p less than 0.01). However, the degree of abnormality in venous volume, venous filling index, and EF was similar in CVI and VV extremities. In summary, although RVF tends to be higher in extremities with CVI when compared with those with VV, there is tremendous overlap between VV and CVI for each of the hemodynamic variables measured by APG. Therefore, the pathophysiology of CVI is likely to involve not only hemodynamic abnormalities but also other factors that have not yet been clearly identified.