Deep Reflux Research Articles

Clinical Presentation and Patterns of Venous Reflux in Thai Patients with Chronic Venous Insufficiency (CVI)

Objective To study the extent of chronic venous insufficiency (CVI) in Thai patients by assessing venous clinical severity scores (VCSSs), venous disability scores (VDSs) and prevalence of lower limb venous reflux in a cohort of patients attending a vascular surgery clinic. Design Prospective comparative cohort study. Material All patients presenting with CVI (Clinical, Etiology, Anatomy and Pathophysiology (CEAP) C4–6) in our vascular surgery clinic between October 2006 and December 2008 were enrolled and compared with the same number of control patients. Method A standardised interview was conducted to document each patient’s history of venous disease, VCSS and VDS. Duplex ultrasonography of selected superficial and deep veins was performed. Results There were 41 patients, mean age 58 years and a mean body mass index (BMI) of 26.7. Of 58 limbs, 35%, 19% and 47% were of CEAP clinical stages C4, C5 and C6, respectively. Previous deep vein thrombosis (DVT) was reported by 7% and major leg trauma by 9% of patients. The mean VCSS was 9.7 and mean VDS was 1.0. VDS 2 or 3 were found in 10% of patients. The VCSS 2 and 3 for pain, oedema and inflammation were found in 22%, 26% and 0% of C6 legs. The prevalence of combined superficial and deep vein reflux was 71%. The prevalence of isolated superficial and deep vein reflux were 8% and 17%, respectively. One patient had iliac vein occlusion. Compared with the control group, risk factors that were found to be significant were physical findings of varicose veins, history of leg trauma, standing posture and BMI. Conclusions Thai patients with CVI were relatively young. Visible varicose veins, pain, oedema and inflammation were uncommon and most patients could maintain their usual activities despite advanced venous disease. An association with obesity was not common. Despite a low prevalence of a history of previous DVT, the prevalence of deep vein reflux was high and commonly combined with superficial venous reflux.

Invited commentary

Drs Raju, Darcey, and Neglen add more information about the important role of venous obstruction to the syndrome of chronic venous insufficiency (CVI) in patients with deep venous reflux disease. From my perspective, the most important findings of this study include: venous stenting improved the rates of healed ulcers, freedom of ulcer-recurrence rates in legs with healed ulcers (C5), and freedom from leg dermatitis; venous stenting improved pain and swelling at 5 years with no differences between nonthrombotic and post-thrombotic obstructions, limbs with severe vs moderate reflux, and limbs with axial and segmental reflux; venous stenting did not result in a deterioration of reflux parameters; and deep venous reflux can be initially ignored if it is combined with iliac vein obstruction. The authors of the current study have been leaders in the area of iliac venous obstruction treatment, and they have the largest world experience using venoplasty and stenting. They used large caliber stents (14-18 mm), covered all lesions without skip areas, extended stents into the inferior vena cava (IVC) 3 to 5 cm, and extended stents below the inguinal ligament as necessary. The patients exhibited advanced chronic venous disease with all having deep venous reflux, 59% demonstrating severe global reflux, 42% showing deep axial reflux, and 65% having superficial venous reflux in addition. By intravascular ultrasound (IVUS) scan, the percent stenosis was 74%, and despite this only 43% demonstrated collaterals on venography suggesting that this venographic sign leaves much to be desired. Only a small percentage of patients required open valve reconstructions by the authors, a group that has written extensively on these vein valve procedures in the past. It is surprising that the results were so good in which only the obstructive component of the disease was treated. The authors have suggested that nonthrombotic iliac vein lesions (NIVL) play a pivotal “permissive” role in the development of chronic venous insufficiency, and the current study supports this suggestion. How can this study be put into context? As the authors suggest, “a stepwise correction of pathology may be applied using initially minimally invasive techniques.” One cannot comment on saphenous vein ablation related to iliac vein stenting from the current study as limbs with concurrent saphenous ablation performed along with stenting were excluded, as were limbs with reflux confined only to the superficial venous system. However, the current study suggests that if iliac venous obstruction is part of the pathophysiology of CVI, iliac venous stenting should be performed as first-line therapy. Unexpected major role for venous stenting in deep reflux diseaseJournal of Vascular SurgeryVol. 51Issue 2PreviewTreatment of chronic venous insufficiency (CVI) has largely focused on reflux. Minimally-invasive techniques to address superficial and perforator reflux have evolved, but correction of deep reflux continues to be challenging. The advent of intravascular ultrasound (IVUS) scan and minimally invasive venous stent technology have renewed interest in the obstructive component in CVI pathophysiology. The aim of this study is to assess stent-related and clinical outcomes following treatment by iliac venous stenting alone in limbs with a combination of iliac vein obstruction and deep venous reflux. Full-Text PDF Open Archive

Unexpected major role for venous stenting in deep reflux disease

Treatment of chronic venous insufficiency (CVI) has largely focused on reflux. Minimally-invasive techniques to address superficial and perforator reflux have evolved, but correction of deep reflux continues to be challenging. The advent of intravascular ultrasound (IVUS) scan and minimally invasive venous stent technology have renewed interest in the obstructive component in CVI pathophysiology. The aim of this study is to assess stent-related and clinical outcomes following treatment by iliac venous stenting alone in limbs with a combination of iliac vein obstruction and deep venous reflux. A total of 528 limbs in 504 patients, ranging in age from 15 to 87, underwent IVUS-guided iliac vein stent placement to correct obstruction over an 11-year period. The etiology of obstruction was nonthrombotic in 196 (37%), post-thrombotic in 285 (54%) limbs, and combined in 47 (9%). Clinical severity class of CEAP was C3 in 44%, C(4,5) in 27%, and C6 in 25% of stented limbs. Deep venous reflux was present in all limbs, associated with superficial and/or perforator reflux in 69%. Reflux was severe in 309/528 (59%) limbs (reflux multisegment score > or = 3) and 224/528 (42%) limbs had axial reflux. Venography and other functional tests had poor diagnostic sensitivity to detect obstruction, which was ultimately diagnosed by IVUS. The IVUS-guided iliac vein stenting was the only procedure performed and the associated reflux was left uncorrected. There was no mortality; morbidity was minor. Cumulative secondary stent patency was 88% at 5 years; no stent occlusions occurred in nonthrombotic limbs. Cumulative rates of limbs with healed active ulcers, freedom of ulcer recurrence in legs with healed ulcers (C5), and freedom from leg dermatitis at 5 years were 54%, 88%, and 81%, respectively. Cumulative rate of substantial improvement of pain and swelling at 5 years was 78% and 55%, respectively. Quality of life improved significantly. Reflux parameters did not deteriorate after stenting. Iliac venous stenting alone is sufficient to control symptoms in the majority of patients with combined outflow obstruction and deep reflux. Partial correction of the pathophysiology in limbs with multisystem or multilevel disease can provide substantial symptom relief. Percutaneous stent technology in concert with other minimally-invasive techniques to address superficial and/or perforator reflux offers such partial correction in limbs with advanced CVI and complex venous pathology. Open correction of obstruction or reflux is now required only infrequently as a "last resort".

Endoscopically directed external support of femoral vein valves

This study investigated the optimization of indications to external valve support using the Vedensky Spiral for primary deep venous reflux based on the femoral vein proximal (ostial) valve anatomy type. The external Vedensky Spiral was used for correction of valvular insufficiency in 28 extremities of 24 patients (18 women, 6 men) during 1998 to 2002. Patients were a mean age of 54.6 years (range, 32-76 years). The clinical manifestation was C(4) in 10 limbs and C(5) in 18 limbs. Primary axial deep reflux was present in all 28 extremities, and axial superficial reflux was also present in 26. Duplex scanning and descending phlebography were used to estimate the functional condition of the deep vein valves. Fibrophleboscopy intraoperatively to study the anatomic status of the femoral vein valves and for checking the repaired valve function was used. Phleboscopy showed the following anatomy of ostial valves of the femoral vein: 16 valves had wide separation of cusps, 11 had elongation of cusps, and one had a monocusp. The competence of femoral vein ostial valves was completely restituted in all cases with wide separation of cusps. Multiple corrections were performed in cases with incomplete competence of the ostial valve (valve with elongation of cusps or monocusp). External valve support by the Vedensky Spiral is an effective and simple method of correction of incompetent femoral vein valves in limbs with primary deep venous reflux. The technical success of the intervention depends on the type of valve insufficiency and the correct choice of spiral diameter.

Randomized trial of medical compression stockings versus two-layer short-stretch bandaging in the management of venous leg ulcers

SummaryA prospective randomized clinical trial was undertaken to compare a medical compression stockings with two-layer short-stretch bandaging in the management of venous leg ulcers. Study endpoints were number of completely healed wounds and the clinical parameters predicting the outcome. Patients, methods: Eighty patients with venous leg ulcers were included in this study, and ultimately allocated into two comparative groups. Group A consisted of 40 patients (25 women, 15 men). They were treated with the compression stockings (25–32 mmHg) and drug therapy. Group B consisted of 40 patients (22 women, 18 men). They were treated with the short-stretch bandages (30–40 mmHg) and drug therapy, administered identically as in group A. Results: Within two months the 15/40 (37.50%) patients in group A and 5/40 (12.50%) in group B were healed completely (p = 0.01). For patients with isolated superficial reflux, the healing rates at two months were 45.45% (10/22 healed) in group A and 18.18% (4/22 healed) in group B (p = 0.01). For patients with superficial plus deep reflux, the healing rates were 27.77% (5/18 healed) in group A and 5.55% (1/18 healed) in group B (p = 0.002). Comparison of relative change of the total surface area (61.55% in group A vs. 23.66% in group B), length (41.67% in group A vs. 27.99% in group B), width (46.16% in group A vs. 29.33% in group B), and volume (82.03% in group A vs. 40.01% in group B) demonstrated difference (p = 0.002 in all comparisons) in favour of group A. Conclusion: The medical compression stockings are extremely useful therapy in enhancement of venous leg ulcer healing (both for patients with superficial and for patients who had superficial plus deep reflux). Bandages are less effective (especially for patients with superficial plus deep reflux, where the efficiency compared to the stockings of applied compression appeared dramatically low). These findings require confirmation in other randomized clinical trials with long term results.

Percutaneous placed bioprosthetic venous vaive in the treatment of deep vein reflux: Animal experiments and clinical trials

Objective To evaluate the efficiency of percutaneously placed bioprosthetic bicuspid venous valve(BVV)in the treatment of deep vein insufficiency in animal experiments and clinical trials.Methods BVV was made of two pieces of lyophilized porcine small intestinal submucosa(SIS)which were attached to a stent frame.Three kinds of BVVs(BVV1,BVV2,BVV3)was developed using different kinds of stent frames and different Methods of attachment. BVV1,BVV2 and BVV3 were percutaneouslv placed into ovlne's jugular veins acrossed the nature valves.Ascending and descending angiography were performed before and after BVVs placement.The patency of veins and the function of valves was evaluated during 5 weeks to 6 months follow-up. In clinical trial,BVV1 and BVV3 were percutaneouslv placed into 3 and 15 patients with chronic venous insufficiency(CVI)respectively.The patency of veins and the function of valves was also evaluated during 1 to 3 years' follow-up.Results In animal experiment,BVV1,BVV2,and BVV3 were placed to 24,26 and 12 ovine's jugular veins respectively.During 5 weeks to 6 months followup period,22(88.0%),24(92.3%)and 12 of the BVVs exhibited good function.Endothelium of both surfaces of SIS leaflets was complete in approximately 3 months. SIS was graduallv reabsorbed and replaced by the host's own cells.Three BVV1 were placed into 3 patients with CVI.At the third year's follow-up,symptoms relieved in 2 cases and no change of clinical symptoms was found in 1 patient.BVV3 were percutaneously placed into 15 patients with advanced symptomatic CVI.At one month and 3 months' followup after BVV3 placement,all BVV3 functioned well. However,BVV3 were flexible and functioned well in only 4 cases at 1 year's follow-up.Intravascular ultrasound revealed thickened rigid cusps with valve leakage of difierent Jevcls and no symptom resolved in 11 cases. Conclusions Percutaneous implantation of bioprosthetic BVV is a promising method in the treatment of CVI.Intimal hyperplasia is an important factor which damages long-term durability and flexibility. Key words: Venous valve; Radiology; interventional; Stents

Reversal of Deep Vein Reflux After Successful Stenting in a Patient With Venous Hypertension After Thigh Access Graft Creation

Presented here is a case of reversal of deep vein reflux after successful stenting in a patient with venous hypertension and valve incompetence after thigh angioaccess creation. The patient with exhausted upper-extremity access sites underwent a loop graft in the upper thigh. Six months later, the patient developed leg edema and significant femoral vein reflux on duplex ultrasound. Fistulography revealed an iliac vein stenosis, which was treated successfully with stenting. The edema and reflux on duplex promptly resolved. In similar cases, reflux may be a consequence of functional valve incompetence and can be reverted by timely treating the underlying stenosis.

Stenting of the venous outflow in chronic venous disease: Long-term stent-related outcome, clinical, and hemodynamic result

Stenting of chronic nonmalignant obstruction in the venous outflow tract started in earnest in 1997. Data sets are now available to perform long-term analysis of stent-related outcome and clinical and hemodynamic results of this intervention. From 1997 to 2005, 982 chronic nonmalignant obstructive lesions of the femoroiliocaval vein were stented under intravascular ultrasound guidance. Median patient age was 54 years (range, 14 to 90 years), the female/male was 2.6:1, and left/right limb symptoms, 2.4:1. Clinical score of CEAP was 2 in 7%, 3 in 47%, 4 in 24%, 5 in 5%, and 6 in 17%; primary/secondary etiology was 518:464. Stent-related outcome (morbidity, thrombotic events, patency, in-stent recurrent stenosis), clinical outcome, quality of life (QOL) as assessed by the Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ), and hemodynamics were evaluated before and after intervention. Monitoring for 94% of patients lasted a mean 22 months (range, 1 to 107 months). Stenting was performed with no mortality (<30 days) and low morbidity. Thrombotic events were rare (1.5%) during the postoperative period (<30 days) and during later follow-up (3%). At 72 months, primary, assisted-primary, and secondary cumulative patency rates were 79%, 100%, and 100% in nonthrombotic disease and 57%, 80%, and 86% in thrombotic disease, respectively. Cumulative rate of severe in-stent restenosis (>50%) occurred in 5% of limbs at 72 months (10% in thrombotic limbs, 1% in nonthrombotic limbs). The main risk factors associated with stent occlusion were the presence and severity of thrombotic disease; thrombophilia by itself was not a risk factor. The median pain score and degree of swelling decreased significantly poststent. Severe leg pain (visual analogue scale >5) and leg swelling (grade 3) decreased from 54% and 44% prestent to 11% and 18% poststent, respectively. At 5 years, cumulative rates of complete relief of pain and swelling were 62% and 32%, respectively, and ulcer healing was 58%. The mean CIVIQ scores of QOL improved significantly in all categories. Mean hand-foot pressure differential decreased and mean ambulatory venous pressure improved in stented limbs with no concomitant reflux. The hemodynamic response was modified, depending on the presence of deep and superficial reflux in subsets of patients with adjunct saphenous procedures. No increase in venous reflux was observed. Venous stenting can be performed with low morbidity and mortality, long-term high patency rate, and a low rate of in-stent restenosis. It resulted in major symptom relief in patients with chronic venous disease, which was not consistently reflected in any substantial hemodynamic improvement by conventional measurements. The beneficial clinical outcome occurred regardless of presence of remaining reflux, adjunct saphenous procedures, or etiology of obstruction.

Ultrasound-Guided Percutaneous Ablation for the Treatment of Perforating Vein Incompetence

Recent advances in catheter-based endovenous interventions have broadened our understanding in the pathophysiology and therapeutic strategies of chronic venous insufficiency, a condition that can be caused by abnormality of various lower extremity venous structures, including superficial or deep vein reflux or incompetent perforating veins. This article reviews the history and therapeutic principles of percutaneous ablation of perforators (PAPs). Discussions related to treatment strategies and procedural techniques of PAPs using radiofrequency ablation, laser energy, and sclerosant injection are provided. Current clinical results of PAPs with radiofrequency and laser energy ablation as a treatment modality of chronic venous insufficiency are also discussed.

Chronic Venous Obstruction: Diagnostic Considerations and Therapeutic Role of Percutaneous Iliac Stenting

Iliac venous outflow obstruction has an important role in the expression of symptomatic chronic venous insufficiency. This anatomic obstruction is frequently overlooked, owing in part to diagnostic difficulty. The combination of venous obstruction and reflux leads to more severe clinical disease. Current diagnostic modalities do not allow an definitive assessment of hemodynamically critical venous obstruction. No single invasive or noninvasive study can accurately detect borderline obstruction of potential hemodynamic significance. A high index of suspicion is critical in the initial recognition of chronic venous obstruction. The diagnosis relies on clinical signs and symptoms and radiologic assessment of morphologic venous outflow obstruction. Treatment strategy should be based on the results of morphologic investigations such as transfemoral phlebography or, preferably, intravascular ultrasonography. Percutaneous iliac venous stenting offers a safe and efficient method to correct pelvic venous obstruction. Percutaneous iliac stenting does not preclude subsequent venous bypass or corrective superficial and deep reflux surgery. This article reviews the etiologic factors and diagnostic modalities of iliac venous obstruction. The therapeutic role of percutaneous iliac stenting in the management of venous obstruction is also discussed.

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

Objective To determine whether recurrence of leg ulcers may be prevented by surgical correction of superficial venous reflux in addition to compression. Design Randomised controlled trial.Setting Specialist nurse led leg...

VS13P THE IMPACT OF THE ESCHAR TRIAL ON CLINICAL PRACTICE

The ESCHAR trial, published June 2004, showed that patients with venous ulceration who had superficial or mixed superficial and segmental deep venous reflux had a decreased likelihood of recurrent ulceration if they were treated with superficial venous surgery. This prompted us, firstly, to review our service to see if we were following this level one evidence; secondly to estimate how many of our patients could benefit from adopting this practice.Method Retrospective audit of all patients attending a nurse‐led ulcer clinic for a 6 month period between June and December 2004.Results 163 patients attended during the audit period. Data were retrieved for 146. Of these only 54 (37%) had purely venous ulceration on clinical assessment, of whom 31 had a venous duplex scan. 21 patients had superficial only, or mixed superficial and deep reflux; 8 had no reflux; 2 had deep reflux only. Of these 21 patients who could potentially be suitable for superficial venous surgery, 1 had deep venous occlusion, 4 patients refused surgery, 4 were considered unsuitable for surgery on medical grounds, 7 were not assessed for surgery, only 3 patients were awaiting superficial venous surgery.Conclusion Despite the publication of evidence supporting superficial venous surgery in selected patients only 3/146 (2%) patients attending our clinic were listed for venous surgery. However 7/21 (33%) were not assessed for treatment. This study demonstrates the inertia in adopting “best evidence” into clinical practice. Even so the numbers of leg‐ulcer patients likely to benefit from surgery appears surprisingly small.

Mutations in FOXC2 Are Strongly Associated With Primary Valve Failure in Veins of the Lower Limb

Mutations in the FOXC2 gene cause lymphedema distichiasis, an inherited primary lymphedema in which a significant number of patients have varicose veins. Because lymphedema distichiasis is believed to be caused by lymphatic valve failure (reflux), and FOXC2 is highly expressed on venous valves in mouse embryos, we tested the hypothesis that FOXC2 mutations may be linked to venous valve failure and reflux. The venous system of the leg was investigated with Duplex ultrasound. Pathological reflux was recorded by color Duplex ultrasound in all 18 participants with a FOXC2 mutation, including 3 without lymphedema. Every participant with a mutation in FOXC2 showed reflux in the great saphenous vein (n=18), compared with only 1 of 12 referents (including 10 family members; P<0.0001, Fisher exact test). Deep vein reflux was recorded in 14 of 18 participants. FOXC2 is the first gene in which mutations have been strongly associated with primary venous valve failure in both the superficial and deep veins in the lower limb. This gene appears to be important for the normal development and maintenance of venous and lymphatic valves.

Leg ulcer treatment by superficial vein surgery and saline-gauze dressing

Rolandas Dagilaitis, Vytautas Triponis, Ingrida Gudgalytė, Dalia TriponienėVilnius University Centre of Vascular Surgery,Antakalnio str. 57, LT-10207 Vilnius, LithuaniaE-mail: vytautas.triponis@mf.vu.lt Objective To determine the effectiveness of phlebectomy and topic saline in patients with leg ulcer caused by isolated superficial vein reflux. Materials and methods One hundred and thirty consecutive patients with 143 ulcers were operated for superficial varicose veins and venous ulcer. Patients with deep reflux, peripheral arterial disease (ankle/brachial index &lt;0.9), diabetes, history of circular venous ulcer, malignancies, mental disorders, musculoskeletal diseases limiting patient’s physical activity and edema of non venous origin were excluded from the study. Past history data were recorded by questionnaires which included the duration of the ulcer, the number of recurrences, characteristic of compression therapy and topic agents used for ulcer care. Ulcer size was evaluated according to its largest dimension. Operations were performed under regional anaesthesia. All patients were followed at 1, 3, 6, 12 and 24 months. No compression therapy was advocated postoperatively. Results Ulcer manifestation span was from 1 to 33 years, 6.47±0.55 years on the average (p &lt; 0.0001). Preoperative compression therapy was inadequate in all patients, local treatment was carried out with large range of antiseptic solutions. Postoperative healing rate at 3 months was as follows: 95.8% for ulcers &lt; 3 cm , 79% and 37.7% for ulcers 3-6 cm and &gt;6 cm respectively. The healing process was complete in 135 (94.4%) ulcers at 1 year. One healed ulcer (0.7%) recurred between 6 and 12 months, 7 ulcers &gt;6 cm showed reepithelialization being in process. Conclusion Phlebectomy in cases of isolated superficial vein reflux is able to heal venous ulcers in majority of patients. The healing rate was correlative with ulcer size and duration. Surgery plus saline-gauze local treatment significantly reduced the costs of venous ulcer treatment. Key words: leg ulcer, superficial vein surgery, topical treatment

Leg ulcer treatment by superficial vein surgery and saline-gauze dressing

Rolandas Dagilaitis, Vytautas Triponis, Ingrida Gudgalytė, Dalia TriponienėVilnius University Centre of Vascular Surgery,Antakalnio str. 57, LT-10207 Vilnius, LithuaniaE-mail: vytautas.triponis@mf.vu.lt Objective To determine the effectiveness of phlebectomy and topic saline in patients with leg ulcer caused by isolated superficial vein reflux. Materials and methods One hundred and thirty consecutive patients with 143 ulcers were operated for superficial varicose veins and venous ulcer. Patients with deep reflux, peripheral arterial disease (ankle/brachial index &lt;0.9), diabetes, history of circular venous ulcer, malignancies, mental disorders, musculoskeletal diseases limiting patient’s physical activity and edema of non venous origin were excluded from the study. Past history data were recorded by questionnaires which included the duration of the ulcer, the number of recurrences, characteristic of compression therapy and topic agents used for ulcer care. Ulcer size was evaluated according to its largest dimension. Operations were performed under regional anaesthesia. All patients were followed at 1, 3, 6, 12 and 24 months. No compression therapy was advocated postoperatively. Results Ulcer manifestation span was from 1 to 33 years, 6.47±0.55 years on the average (p &lt; 0.0001). Preoperative compression therapy was inadequate in all patients, local treatment was carried out with large range of antiseptic solutions. Postoperative healing rate at 3 months was as follows: 95.8% for ulcers &lt; 3 cm , 79% and 37.7% for ulcers 3-6 cm and &gt;6 cm respectively. The healing process was complete in 135 (94.4%) ulcers at 1 year. One healed ulcer (0.7%) recurred between 6 and 12 months, 7 ulcers &gt;6 cm showed reepithelialization being in process. Conclusion Phlebectomy in cases of isolated superficial vein reflux is able to heal venous ulcers in majority of patients. The healing rate was correlative with ulcer size and duration. Surgery plus saline-gauze local treatment significantly reduced the costs of venous ulcer treatment. Key words: leg ulcer, superficial vein surgery, topical treatment

Combined saphenous ablation and iliac stent placement for complex severe chronic venous disease

Severe chronic venous disease frequently has a complex pathophysiology. This study describes results after combined interventions to correct outflow obstruction and superficial reflux, even in the presence of deep venous reflux. Between 1997 and 2005, 99 limbs in 96 patients had percutaneous iliofemoral venous stenting combined with great saphenous vein (GSV) stripping (39 limbs), or percutaneous GSV ablation performed by radiofrequency (27 limbs) or laser (33 limbs). Clinical severity score in CEAP was C4 in 51 limbs, C5 in eight limbs, and C6 in 40 limbs; median age was 56 years (range, 27 to 87 years); left-right limb ratio, 2.3:1; female-male ratio, 1.8:1; primary-secondary etiology, 58:41. Perioperative investigations included visual analogue pain scale (VAS), degree of swelling (grade 0 to 3); quality-of-life questionnaire; venous filling index in milliliters per second (VFI90), venous filling time in seconds (VFT), percentage in ambulatory venous pressure drop (AVP), duplex Doppler scanning, and radiologic studies. Clinical follow-up was performed in 97 (98%) of 99 for up to 5.5 years. Axial deep reflux was found in 27% (27/99). At least three venous segments were refluxing in 40% of limbs. Preoperative hemodynamic parameters reflected the presence of reflux and improved significantly (P < .01) after the procedure (VFI90, 3.8 to 2.3 mL/s; VFT, 11 to 16 seconds; AVP, 55% to 65%). No patients died, and the morbidity with endovenous GSV ablation was largely limited to ecchymosis and thrombophlebitis in the thigh area. Cumulative primary, assisted primary, and secondary stent patency rates at 4 years were 83%, 97%, and 97%, respectively. After treatment, limb swelling and pain substantially improved. The rate of limbs with severe pain (>or=5 on VAS) fell from 44% to 3% after intervention. Gross swelling (grade 3) decreased from 30% to 6% of limbs. Cumulative analysis showed sustained complete relief of pain (VAS = 0) and swelling (grade 0) after 4 years in 73% and 47% of limbs, respectively. Ulcers healed in 26 (68%) of 38 ulcerated limbs. Cumulative ulcer-healing rate was 64% at 48 months. All quality-of-life categories significantly improved after treatment. The single-stage combination of percutaneous venous stenting and superficial ablation in patients with severe chronic venous disease is safe, gives excellent symptom relief and improvement of quality of life, and a well-maintained ulcer-healing rate. It seems logical to initially perform multiple minimally invasive interventions rather than open surgery. Any associated deep reflux can initially be ignored pending clinical response to the combined intervention.

The nonsaphenous vein of the popliteal fossa: Prevalence, patterns of reflux, hemodynamic quantification, and clinical significance

A large tortuous vein coursing over the posterior aspect of the knee and the upper calf may give rise to a constellation of varicose veins unrelated to the great (GSV) or small (SSV) saphenous veins. Designated the popliteal fossa vein (PFV), it perforates the deep popliteal fascia and empties into the deep system. We examined the prevalence, anatomic reflux patterns, hemodynamic role, and clinical significance of the PFV. We examined 543 patients (818 limbs) with venous disease, aged 14 to 94 years (median, 55 years). The study consisted of group A, comprising limbs with a PFV, and group B, formed by the remaining limbs. The history, clinical examination, and venous duplex scan findings were analyzed retrospectively. Venous clinical severity and venous segmental disease scores of group A were compared with those of an equal number of CEAP-, sex-, and age-matched control limbs. In situ venous hemodynamics of the PFV obtained with duplex scan are reported. A PFV was found in 24 (2.93%) of 818 limbs (95% confidence interval [CI], 1.8%-4.1%); 24 (4.4%) of 543 subjects (95% CI, 2.7%-6.2%), 12 men and 12 women aged 23 to 82 years (median, 54 years) had a PFV. CEAP clinical classes in limbs with a PFV were as follows: C2, 15 limbs; C3, 5 limbs; C4, 2 limbs; C5, 1 limb; and C6, 1 limb. Proximal and distal (92%), superficial (100%), perforator (87.5%), and complex-pattern (41.7%) reflux occurred more often in group A (P < .01). Incompetence in the GSV (75%), posterior arch, and posteromedial and saphenous tributaries was also more frequent in group A (P < .05). SSV reflux in group A (29%) matched that in group B. The PFV terminated at the deep system (96% in the popliteal vein) above the SSV (median distance, 1.5 cm; 95% CI, 0.5-2 cm). The odds ratio for a PFV in limbs with prior SSV disconnection was 5.68. Deep reflux was evenly distributed in group A (41.7%) and group B (27%). The prevalence of incompetent perforators was 283% (95% CI, 194%-373%) in group A and 96% (95% CI, 95%-98%) in group B (P < .001). PFV tributaries were distributed at the popliteal area (100%); the posterior (87.5%), medial (62.5%), and lateral (37.5%) upper calf; and the posterior distal thigh (17%), often projecting to the posterior GSV arch (50%). The (median) peak velocity of reflux in the PFV was 82.6 cm/s, the mean velocity was 17.7 cm/s, the duration was 2.4 seconds, the volume flow was 231.5 mL/min, and the expelled volume was 9.3 mL. The median diameter of the PFV at the crossing of the fascia was 0.527 cm. Venous clinical severity (range, 2-17; median, 5.5) and venous segmental disease (range, 0.5-8; median, 2.75) scores in limbs with a PFV exceeded (P <or= .04) those of the control limbs. With a prevalence of 4.4%, the PFV presents in limbs featuring complex reflux patterns involving all three venous systems proximally and distally. Limbs with a PFV have a higher propensity for GSV and superficial tributary reflux and have perforator vein incompetence three times more often than limbs without this vein. The PFV perforates the deep popliteal fascia terminating at the deep system (ie, the popliteal vein in 96%) distinctly above the SSV. In light of its reflux dynamics, nearing or exceeding those of severely impaired perforator veins, and the complex patterns of reflux (venous segmental disease) and venous clinical severity (high venous clinical severity scores) of the affected limbs, clinical and investigational awareness of the PFV is warranted.

External Venous Valve Plasty (EVVP) in Patients with Primary Chronic Venous Insufficiency (PCVI)

To evaluate the patency of EVVP and its effect in symptom relief, ulcer healing and ulcer-free period in patients with PCVI. Between 1993 and 2004, 1800 patients with CVI were evaluated and seventeen with PCVI were selected for EVVP. They were all investigated with ambulatory venous pressure measurement (AVP), colour duplex ultrasound (CDU), ascending venography and descending video venography. The CEAP classification was used to group the patients. Six patients were C4, four C5 and seven C6. All had deep reflux and high levels of AVP. All procedures were technically successful. The ulcer healing rate was 4/7 (57%) within 3 months. All C4 patients experienced symptom improvement postoperatively and had a median recurrence free period of 72 (range 60-122) months. The C5 group had an median ulcer free period of 61 months (12-72) and the C6 of median 48 (12-72) months. Single valve plasties (4) reached a median competence period of 48 months (12-72), 12 multiple valve plasties at the same level show a median 78 months (63-122) and 10 multilevel repairs median 54 months (12-96). Multiple valve plasties at the same level (multi-station plasties) performed on the C4 group seemed to yield the longest durability with a median of 103 months (84-122). EVVP with an ulcer healing rate of 57% and satisfactory symptom improvement seems to be an alternative of surgical treatment for selected patients with PCVI. The durability of this technique seems to be related to clinical severity and the multiplicity of repairs.

The morphology of the varicose short saphenous system

Objective: Surgery for the varicose short saphenous vein (SSV) remains unsatisfactory. Specific problems include locating the saphenopopliteal junction (SPJ) and whether the trunk should be stripped. Recurrence rates are high. The objective was to review the morphology of varicose SSV and to address these aspects. Methods: Retrospective study of consecutive patients scheduled for SSV surgery based on initial continuous wave Doppler assessment. Detailed analysis of preoperative duplex ultrasound examinations with quantified reflux. Results: A total of 56 limbs (unilateral) were studied, male to female ratio was 18:38 and mean age was 51 years. SPJ: severe reflux in 47, mean diameter 8.1 mm (all above the skin crease [mean 2.7 cm]). Reflux was 'focal', being confined to the peri-junctional area with normal sized and competent distal short saphenous trunks in 29. In the remainder, incompetence was 'complete' with dilatation and reflux of the entire system. In only one limb did varicosities arise distally from a proximally competent system. Long saphenous vein ( LSV): coexistent reflux in 17, with communications with the SSV in 11. Deep reflux: at least one segment of deep reflux was found in 24 limbs. In this small study, no significant association with other morphology was found apart from 'complete' SSV reflux. Conclusion: The SPJ is usually severely incompetent, enlarged and sited above the skin crease. The morphology of the varicose SSV exhibits important differences from the LSV. In over half, incompetence is 'focal', confined to the peri-junctional vein and the distal trunk is competent suggesting a case for selective trunk stripping. Varicosities arising from a distally incompetent short saphenous trunk are uncommon.

Reduction in deep vein reflux after concomitant subfascial endoscopic perforating vein surgery and superficial vein ablation in advanced primary chronic venous insufficiency

Subfascial endoscopic perforating vein surgery (SEPS) and superficial vein surgery (SVS) have been the recommended treatment for advanced chronic venous insufficiency (CVI), despite a high prevalence of deep vein reflux in these patients. The anatomic and hemodynamic results of these procedures, however, remain uncertain. It is hypothesized that concomitant SEPS and SVS would result in a reduction of deep vein reflux in patients with advanced primary CVI. We investigated the effect of concomitant SEPS and SVS on deep vein reflux as well as the associated hemodynamic and clinical changes after surgery in a cohort of patients with advanced primary CVI. We prospectively evaluated 53 consecutive SEPSs with concomitant SVS procedures in 47 patients with advanced primary CVI. There were 25 men and 22 women with a mean age of 58 years at operation. Thirty-four procedures (64%) were performed for limbs with active venous ulcers (class 6), and the other 19 procedures were performed for 15 class 5 limbs, one class 4a limb, and three class 4b limbs, respectively. Duplex scan and air plethysmography were performed before operation, at 1 month, and at 1 year after operation. The patients were followed up regularly with clinical assessment, and the ulcer healing and recurrence rates were documented. The proportion of limbs with common femoral vein incompetence decreased from 68% to 28% at 1 month and to 32% at 1 year after operation. The proportion of limbs with deep vein incompetence at more than one site also decreased from 42% to 15% at 1 month and to 12% at 1 year after concomitant SEPS and SVS. Venous hemodynamics as measured by air plethysmography improved significantly after operation. The cumulative ulcer healing was 85% at 3 months and 97% at 6 months. With a mean follow-up of 31 +/- 16 months, all ulcers healed. Only three recurrent ulcers (6%) were detected during the follow-up period. Concomitant SEPS and SVS are effective in reducing deep vein reflux and results in hemodynamic and clinical improvements in patients with advanced primary CVI. Deep vein reconstruction procedures may not be necessary in these patients.