Regarding "Hemodynamic and clinical improvement after superficial vein ablation in primary combined venous insufficiency with ulceration".

Abstract

A recent article by Padberg et al. (J Vasc Surg 1996;24:711-8) reported the beneficial effects of combined saphenous and perforating vein ligation in patients with venous ulceration caused by primary incompetence of the saphenous and deep systems. However, we believe a number of points need further discussion. First, although it is a noninvasive technique, air plethysmography (APG) gives no direct measurement of venous function. We would advocate the use of ambulatory venous pressure (AVP) measurement, which is considered to be the “gold standard” test of venous function, giving direct measurement of venous filling times (a measure of venous reflux) and the drop in venous pressure achieved on exercise (a measure of calf pump efficiency). Venous hypertension is, after all, the root cause of venous ulceration, and as such this parameter of venous function ought to be measured directly. AVP measurements are simple to perform and would have been easily incorporated into the methods because each patient underwent phlebography as part of the protocol. Second, the definitive test of saphenous surgery is not necessarily its influence on venous hemodynamics but on its clinical impact for the patient. With regard to ulcer healing, this cannot be assessed in this paper because the ulcers were healed before surgery by compression therapy and the follow-up period of 2 years is too short to meaningfully assess ulcer recurrence rates.1Kistner RL Valve reconstruction for primary valve insufficiency.in: Atlas of venous surgery. W.B. Saunders, Philadelphia1992: 125-133Google Scholar, 2Bradbury AW Ruckley CV Foot volumetry can predict recurrent ulceration after subfascial ligation of perforators and saphenous ligation.J Vasc Surg. 1993; 18: 789-795Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Third, none of the 11 limbs examined had deep venous reflux extending into the crural veins, and five of 11 limbs had competent popliteal segments. Because in the absence of superficial venous reflux popliteal valve incompetency is pivotal in the development of venous ulceration,3Bradbury AW Brittenden J Allan PL Ruckley CV Comparison of venous reflux in the affected and non-affected leg in patients with unilateral venous ulceration.Br J Surg. 1996; 83: 513-515Crossref PubMed Scopus (18) Google Scholar, 4Payne SP London NJ Newland CJ Bell PR Barrie WW Investigation and significance of short saphenous vein incompetence.Ann R Coll Surg Engl. 1993; 75: 354-357PubMed Google Scholar these five limbs possibly had insignificant femoral vein reflux that did not contribute to the overall calf pump dysfunction. This being the case, one would expect improved venous hemodynamics after saphenous vein surgery. The improved venous hemodynamics reported in this paper reflect this, suggesting that this group of patients who have proximal deep vein reflux behave in a similar manner to those who have normal deep veins.5Scriven JM Thrush AJ Hartshorne T London NJM The hemodynamic effect of sapheno-femoral/popliteal disconnection in patients with venous ulceration [abstract].Br J Surg. 1996; 83: 50Crossref PubMed Scopus (8) Google Scholar In limbs where deep venous reflux extends across the knee into the crural veins, saphenous surgery confers no hemodynamic benefit,5Scriven JM Thrush AJ Hartshorne T London NJM The hemodynamic effect of sapheno-femoral/popliteal disconnection in patients with venous ulceration [abstract].Br J Surg. 1996; 83: 50Crossref PubMed Scopus (8) Google Scholar and the authors report two limbs with grade 3 and 4 reflux deteriorating after surgery. Finally, it is interesting to note the authors' final conclusion in suggesting that saphenous vein ligation is required before deep venous reconstruction. If, as is reported here, such sustainable hemodynamic and symptomatic improvements are possible with saphenous ligation alone, why then do the authors feel it necessary to reconstruct the deep system? This paper addresses an important and, to date, unclear clinical situation; however, it does not address the role of saphenous surgery in limbs with below-knee or crural deep reflux and unfortunately assesses venous function in a suboptimal manner. As such it fails to clarify the management of patients who have extensive primary deep venous reflux.