Deep Venous Insufficiency Research Articles

Mercury Strain-Gauge Plethysmography Venous Mode: Non-Invasive Technique of Choice in Vascular Pathology

Mercury strain-gauge plethysmography venous mode is a non-invasive technique for exploration of the haemodynamics of the extremities. The plethysmographic parameters used are: (1) the venous inflow (in ml/100 ml/min); (2) the venous outflow (in ml/100 ml/min); (3) the venous capacity in ml/100ml; (4) the venous distensibility index in ml/100 ml/ mmHg; and (5) the venous pressure measured by ‘hysteresis curve’. This method permits us to analyse the venous haemodynamics of both extremities simultaneously (the normal limb serving as the control), to obtain a precise diagnosis and to appreciate the efficacy of treatment at follow-up. The aetiology of the swollen limb can be precisely identified in 95% of the studied cases: oedema in superficial venous insufficiency, oedema in the deep venous insufficiency, oedema of inflammatory origin, oedema in the arterial insufficiency, oedema of cardiac origin, lymphoedema. During the last 3 years, we have followed up 580 patients with this method.

The Effect of Elastic Compression on Tcpo2 in Limbs with Venous Stasis

A low oxygen tension might contribute to the dermatological changes produced by deep venous insufficiency and venous stasis. Since elastic support is often prescribed for stasis disorders, it would be of value to know whether compression alters the oxygen tension in affected skin. We performed studies in which the transcutaneous Po2 (TcPo2) was determined for the foot or lower leg in subjects with normal veins (n = 9) or with dermatitis caused by documented deep venous insufficiency (n = 14). Measurements were made using O2-sensing electrodes placed 1–2 cm apart; surface temperature was 45°C for one electrode (producing maximal vasodilation of the underlying skin) and 42°C for the other (producing submaximal vasodilation). The vasodilation index (VI = TcPo2 at 42 °C/TcPo2 at 45°C) was used as an index of vasomotor tone. In normal limbs, TcPo2 (mmHg) and VI were affected by the subject's posture (TcPo2 = 38.8 at 42°C and 61.4 at 45°C when supine; 40.8 at 42°C and 74.6 at 45°C when upright with legs dependent; VI = 0.63 supine and 0.53 upright). In limbs with venous stasis, TcPo2 and VI were considerably lower (TcPo2 = 23.6 at 42°C and 51.5 at 45°C when supine; 20.8 at 42°C and 60.5 at 45°C when upright; VI = 0.48 supine and 0.37 upright). Following the application of an elastic wrap to the limbs with stasis, upright values for TcPo2 and VI were substantially improved (TcPo2 with compression = 28.8 at 42°C and 62.4 at 45°C; VI = 0.46). We conclude that (1) TcPo2 is reduced in regions of skin affected by stasis dermatitis, and (2) elastic compression improves TcPo2 (during upright posture) in limbs with stasis dermatitis.

Photoplethysmography in the assessment of venous insufficiency

Photoplethysmography has been used simultaneously with ambulatory venous pressure measurements to study 32 patients. Of the 62 limbs studied, 24 were normal, 20 had primary varicose veins, and 18 had deep valvular incompetence. The results indicate that the photoplethysmographic refilling time can provide a good separation between the three groups when the test is performed in the standing, but not in the sitting, position. However, the test is qualitative because we found a lack of correlation between the short refilling times in limbs with deep venous insufficiency and the ambulatory venous pressure.

The Substitute Valve Operation on the Popliteal Vein in the Treatment of Deep Venous Incompetence of the Lower Extremity

Sixty patients (62 limbs) with chronic incompetence of the deep veins of the lower extremity underwent the "substitute value" operation on the popliteal vein. The results after this operation were assessed clinically, phlebographically, and objectively, by venous pressure measurements, before, and three weeks and one and two years after, operation. The two-year follow-up of the 60 operated patients demonstrated clinical improvement associated with significant reduc tion in the ambulatory venous pressure (AVP) and prolongation of the refilling time (RT). The patients selected for this operation had had either a primary incompetence or a postthrombotic valve incompetence with completely recana lized deep veins. On the basis of their experience and the excellent results, the authors consider this operation the method of choice for eliminating deep ve nous insufficiency.

Recurrent varicose veins.

AbstractWhen Doppler ultrasound was introduced for the assessment of patients with varicose veins, a more accurate clinical appraisal of the pathophysiology of this condition became possible. In particular, it enabled identification of those patients with recurrent varicose veins who had had inappropriate or inadequate initial treatment. It facilitated planning of appropriate further treatment.The more widespread use of radiology, in particular varicography, as a means of preoperative assessment of recurrent varicose veins has enabled a more accurate definition of the abnormal anatomical features. The extension of this principle to the operating room has made surgery for recurrent varicose veins more precise.Patients with varicose veins secondary to deep venous disease remain a problem. When both superficial and deep venous disease are present, superficial venous disease should be treated as appropriate. Deep venous insufficiency will require continued supervision of support maintained by bandages or graduated elastic stockings.

Influence of the profunda femoris vein on venous hemodynamics of the limb. Experience from thirty-one deep vein valve reconstructions.

Venous valve reconstruction in 31 limbs (28 patients) with chronic deep venous insufficiency is analyzed. The indications for operation were primary or secondary deep valvular incompetence with severe reflux and venous hypertension. Valvuloplasty was performed on a proximal valve of the superficial femoral vein (SFV) in 17 limbs and on a common femoral vein valve in two limbs; transplantation of a valve-bearing segment of the axillary vein was made to the common femoral vein in two limbs, to the SFV in seven limbs, and to the popliteal vein in three limbs. The results of valvuloplasty were satisfactory, with six failures observed during a follow-up period extending to 84 months (mean, 44 months). Eight of 12 valve transplant reconstructions failed within 2 years. Patency and competence of the reconstruction were obtained in 27 limbs at the 6-month postoperative control period. The effects on venous pressure were analyzed regarding the presence or absence of reflux into the profunda femoral vein (PFV) with preoperative retrograde phlebography. The results showed significant reduction of the ambulatory venous pressure (p less than 0.05) and increase in venous recovery time (p less than 0.01) in limbs with PFV competence. In limbs in which the PFV was incompetent the pressure values remained unchanged. These findings suggest that the functional state of the PFV is of great importance to the venous hemodynamics of the limb. This study also indicates that the principle of one-level repair in the SFV seems appropriate in limbs with a competent PFV.

Influence of the profunda femoris vein on venous hemodynamics of the limb: Experience from thirty-one deep vein valve reconstructions

Venous valve reconstruction in 31 limbs (28 patients) with chronic deep venous insufficiency is analyzed. The indications for operation were primary or secondary deep valvular incompetence with severe reflux and venous hypertension. Valvuloplasty was performed on a proximal valve of the superficial femoral vein (SFV) in 17 limbs and on a common femoral vein valve in two limbs; transplantation of a valve-bearing segment of the axillary vein was made to the common femoral vein in two limbs, to the SFV in seven limbs, and to the popliteal vein in three limbs. The results of valvuloplasty were satisfactory, with six failures observed during a follow-up period extending to 84 months (mean, 44 months). Eight of 12 valve transplant reconstructions failed within 2 years. Patency and competence of the reconstruction were obtained in 27 limbs at the 6-month postoperative control period. The effects on venous pressure were analyzed regarding the presence or absence of reflux into the profunda femoral vein (PFV) with preoperative retrograde phlebography. The results showed significant reduction of the ambulatory venous pressure (p < 0.05) and increase in venous recovery time (p < 0.01) in limbs with PFV competence. In limbs in which the PFV was incompetent the pressure values remained unchanged. These findings suggest that the functional state of the PFV is of great importance to the venous hemodynamics of the limb. This study also indicates that the principle of one-level repair in the SFV seems appropriate in limbs with a competent PFV.

Rationale and Efficacy of the Substitute "Valve" Operation by Technique II in Deep Venous Insufficiency of the Lower Limb

The substitute "valve" operation by Technique II designed to overcome reflux in the popliteal vein was performed on 105 patients (119 limbs) with deep venous incompetence of the lower limb. There was a five-year follow-up on 101 of them (115 limbs) after operation by Technique II. Results were assessed clinically, by Doppler ultrasound, by venous pressure measurements, and by phlebography. Clinical improvement in 108 of 115 limbs was associated with a decrease in ambulatory venous pressure and prolongation of refilling time with interruption of the popliteal reflux by Doppler (96 limbs) and with phlebographic evidence of a functioning substitute "valve."

Is the vascular laboratory necessary in the management of venous disease?

The author sets forth an assessment of the practical usefulness of the currently available noninvasive laboratory tests in the diagnosis and management of peripheral deep vein thrombosis and chronic venous insufficiency. His standards of evaluation are defined in terms of his personal experience and suggest that these tests, in the setting under discussion, have a value largely limited to patient screening.

Venous function five to eight years after clinically suspected deep venous thrombosis.

One hundred and fifty-four patients, who had been subjected to phlebography 5-8 years previously because of clinical suspicion of deep venous thrombosis (DVT), were investigated to evaluate the frequency of deep venous insufficiency (DVI). The evaluation included clinical examination, registration of subjective complaints and objective measurements with plethysmography, venous pressure and Doppler ultrasound. DVT had been present in 75 legs. There were no statistically significant differences between legs with and without earlier DVT apart from more venous outflow obstruction in the former. DVI was as common after calf vein thrombosis as after more proximal DVT. DVI was more frequent in elderly patients and in patients with a history of previous DVI or DVT. The sufficiency of the popliteal vein seemed to be of great importance in the development of DVI. More than one third of legs without DVT had developed DVI at follow-up.

Venous function after fracture of the lower extremity. A 9-year follow-up of 150 cases.

One hundred and fifty patients were examined 8-10 years after a fracture of the lower limb to evaluate whether the frequency of deep venous insufficiency (DVI) was influenced by the type of fracture. The evaluation included clinical examination, subjective complaints, venous pressure, plethysmography and doppler sonography. Symptoms and signs of DVI were more common in the fractured than in the uninjured limbs, while objectively diagnosed DVI did not differ between the groups. Only minor differences were present in the development of DVI between limbs with various types of fracture (hip fractures were not included in the study). High age and incompetence of the popliteal valves were more important in the development of DVI than the earlier fracture. The frequency of objectively measured DVI in the fractured limbs was 35 per cent and in the uninjured limbs 30 per cent.

The Postphlebitic Syndrome: Pathophysiology, Prevention and Management

Chronic deep venous insufficiency of the lower extremity, usually the result of antecedent venous thrombosis, represents a problem of considerable magnitude for both patient and physician. While the fully developed postphlebitic syndrome is immediately recognized by the most inexperienced medical student, the exact underlying pathogenetic mechanisms remain controversial, available therapeutic options are limited, and the value of surgery is uncertain.

Assessment of deep venous insufficiency by ascending phlebography.

Retrograde femoral phlebography performed in the supine and erect positions are compared. In deep venous insufficiency, the contrast medium passes considerably farther down in the retrograde direction in examinations with the patient in the erect position. A comparison was made between ascending and retrograde techniques in order to find out what predictive value conventional ascending phlebography of the lower limb may have with regard to the function of the valves in the femoral vein. Layering of the contrast medium in the valvular sinus is a very reliable sign of valvular competence and was observed in two-thirds of the cases without deep venous insufficiency. This figure can be increased by a slight modification of the method of examination. Absence of layering does not necessarily indicate deep venous insufficiency.

Physiologic and therapeutic aspects in congenital vein valve aplasia of the lower limb.

Ten patients with congenital vein valve aplasia verified at contrast phlebography were evaluated clinically and by physiologic examinations. All had orthostatic edema and varicose veins, but leg ulcers and other "postphlebitic" sequelae were infrequent. Foot volumetry and measurement of ambulatory foot vein pressures revealed a severe deep venous incompetence with a defective muscle pump function and considerable reflux. Eight limbs were operated on with conventional varicose vein surgery and physiologically re-examined six to 26 weeks after the operation. All had an improved ambulatory pressure reduction (p less than 0.001). Foot volumetry revealed better muscle pump function (p less than 0.01), while the reflux flow was unchanged. Surgery of the incompetent superficial venous system is therefore recommended in cases with deep venous insufficiency due to congenital vein valve aplasia.

Venous insufficiency of the lower limb and stasis ulceration. Changing concepts and management.

In a group of patients studied for venous insufficiency, the incidence of deep venous insufficiency was much higher than previously suspected. Insufficiency of the superficial system, when present, was associated invariably with deep venous insufficiency, suggesting a leading role for the latter condition. Evidence is presented to show that in many instances, such reflux is probably non-thrombotic. The results of various types of direct venous valve surgery in a group of patients are presented.

Direct venous surgery for venous valvular insufficiency of the lower extremity.

Seven patients had severe deep venous insufficiency and recurrent ulceration in eight lower extremities. All incompetent perforating veins had been previously ligated. All limbs were evaluated by dynamic venous pressure measurements. The venous pressure reduction with exercise was recorded, as well as the recovery time. The most accurate indicator of venous valvular incompetence was a short postexercise recovery time. Abnormal hemodynamic findings were correlated with ascending and descending venographic findings. Based on these anatomic and pathophysiologic abnormalities, patients underwent valvular transposition, superficial femoral vein valvuloplasty, or superficial femoral vein ligation. Immediate postoperative recovery time (mean +/- SEM) was improved to 34.5 +/- 18.3 s from 7.9 +/- 2.9 s preoperatively. Postoperative venography demonstrated patency of all anastomoses and absence of reflux into previously incompetent venous systems. All limbs were symptomatically improved after operation, and no venous thrombosis or pulmonary emboll developed. Persistent ulceration, however, continued in one limb.

Venous function in the leg after postoperative thrombosis diagnosed with 125I-fibrinogen uptake test.

The 125I-fibrinogen uptake test (FUT) has been widely used in the past decade to detect postoperative thrombosis. FUT has been shown to correlate well with phlebography, and positive FUT is associated with a high frequency of pulmonary embolism. The long-term venous function of the leg after FUT-detected postoperative thrombosis, however, is inadequately documented. In 179 patients who had been studied after operation with FUT, a follow-up evaluation of FUT as an indicator of risk for development of deep venous insufficiency was made four to five years later. The patients replied to a questionnaire, were clinically examined, and underwent venous strain-gauge plethysmography, venous pressure measurement, and, in some cases, phlebography. No statistically significant differences were found in any of the parameters between legs that had been FUT-positive and those that were FUT-negative at the time of the operation. The frequency of deep venous insufficiency thus was equal in FUT-positive and FUT-negative legs. It was also independent of the site of FUT-detected thrombus in the leg.

After-exercise thermography compared to strain-gauge plethysmography and venous pressure measurements to detect deep venous insufficiency

After-exercise thermography (AET) has been claimed to be a means of detecting deep venous insufficiency. The question was studied in 167 patients four to five years after major surgery. The tests af follow-up included AET, strain-gauge plethysmography and venous pressure measurements in addition to clinical examination and a questionnaire concerning history, symptoms etc. No correlation was found between abnormal AET and objective manifestations of deep venous insufficiency.

After-exercise thermography compared to strain-gauge plethysmography and venous pressure measurements to detect deep venous insufficiency

After-exercise thermography compared to strain-gauge plethysmography and venous pressure measurements to detect deep venous insufficiency

Comparison between the plasminogen activator activity in walls of superficial, muscle and deep veins

Determinations were made of the plasminogen activator activity (PA) of biopsy specimens of the great saphenous vein and at the same level of the femoral or the popliteal vein in 35 patients undergoing amputation of the leg because of arterial insufficiency and in one because of deep venous insufficiency. The PA was measured with a modification of Todd's fibrin slide technique. In 21 patients the PA was also determined in biopsy specimens of a muscle vein at the same level of the leg. The PA of the walls of superficial veins proved significantly lower than that of the walls of deep major veins. No difference in activity was demonstrable between muscle veins and deep major veins. A significant correlation was found between the PA of superficial and deep veins.