Perforating Vein Insufficiency Research Articles

Cutaneous findings in patients with chronic venous insufficiency

Venous hypertension causes many different cutaneous findings such as varicosities, telangiectasia, edema, and pigmentation, dermatitis, and venous ulcers on the skin. This study aims to investigate the cutaneous signs and symptoms of chronic venous insufficiency (CVI) and to examine their contribution to early diagnosis. A total of 150 patients were included in the study who applied to the dermatology outpatient clinic and were diagnosed with skin disease related to CVI or had skin findings. Patient's age, gender, complaints, occupation, additional diseases, drug usage, history of prolonged standing and travel, smoking habit, number of pregnancies, history of varicose veins in the family, dermatological diagnosis/findings, and venous Doppler ultrasonography reports were examined retrospectively. 56% of patients were women. Mean age was 56.69±13.6years. Overall, 82.7% of total patients had at least one skin finding. The most frequent skin findings except varicose veins were insufficiency dermatitis accounted for 32.7% of patients, telangiectasia, and pigmentation which were comprised 25.3%, 19.3% of the total number of patients respectively. In addition to this, 48.7% of patients had itching problems and 32.7% had pain. Moreover, 46% of patients presented superficial vein insufficiency, while 8.7% had deep vein insufficiency. For 47.3% of patients, vein diameter dilation was observed and 11.3% suffered from perforating vein insufficiency. In terms of Clinical-Etiologic-Anatomic-Pathophysiologic (CEAP) classification, scores of 52% of the patients were C3 and lower, while scores of 48% of total patients were C4a and higher. Early diagnosis and treatment of chronic venous insufficiency could prevent further chronic processes such as venous ulceration which is an advanced CVI finding. Thus, assessing the early skin findings might be important to identify the underlying venous insufficiency disease.

Demographic examination of lymphedema seen in the lower extremities

Background: We aimed to indicate the frequency of this disease according to blood groups, other disease types, age, weight and other demographic characteristics.Methods: We examined total of 236 patients who applied to our clinic because of lower extremity edema within 5 years. All patients had a diagnosis of lymphedema. Patients with a diagnosis of congenital lymphedema or a diagnosis secondary to cancer were excluded. Obesity, presence of venous disease, diabetes mellitus and hypertension which are considered as causes of secondary lymphedema were included in the study. Also the relationship between lymphedema patients and blood groups were evaluated.Results: 81% (n:193) of patients were women. The mean age of the patients was 50.71 (±10.28). All patients had diagnosis of lymphedema. Most of patients (n:189) had bilateral lower extremity edema. Body mass index was above 25 in 149 (63.1%) patients. Deep venous insufficiency accompanied in 75 (31.8%) patients. Perforator vein incompetance was observed with lymphedema in 96 (40.7%) patients. The number of diabetic and hypertensive patients was 64 (27.1%) and 67 (28.4%), respectively. Patients with B type blood group constituted the largest patient profile with a rate of 41.9% (n:99).Conclusions: In our study, demographic characteristics were not statistically corolated to lymphedema development, however, the rate of lymphedema in patients with perforating vein insufficiency was statistically significant (p<0.05, P=0.002). The most important point to be considered here is whether lymphedema plays a role in the development of additional pathology or do additional pathologies trigger the development of lymphedema?

Evaluation of perforating venous insufficiency with shear wave elastography: a preliminary study.

The aim of this study was to investigate the efficacy of shear wave elastography (SWE) in the diagnosis of perforating vein insufficiency, and to determine the applicability of these measurements. A total of 140 symptomatic patients with a total of 280 lower extremities were investigated. All patients presented with venous insufficiency (VI) symptoms, and received Doppler ultrasound assessment to determine VI and SWE measurements. The SWE values were measured in the adjacent perivenous tissue of the largest Cockett's perforating vein (PV) of both lower extremities, at the level where they pass the fascia. The Cockett's PV diameter and the presence of reflux in Cockett's PV and the great saphenous vein were compared with SWE values in perivenous tissue of PVs. The SWE values of the perforating vein insufficiency group were significantly higher than those of the normal PV without insufficiency group (P < 0.001). A significant and positive relation was seen between increased PV diameter and SWE values (P < 0.001) and there was a significant relationship between the presence of perforating vein insufficiency and increase in PV diameter. A statistically significant increase was detected in SWE values for the PV for those with reflux in the great saphenous vein (P < 0.001). The best cut-off values that can be used to detect perforating vein insufficiency were found 34.600 for kPa and 3.375 for m/s. SWE may be used effectively in addition to conventional Doppler ultrasound examination in diagnosing and following perforating vein insufficiency.

Studies on the relationship between perforating vein insufficiency and iliac compression syndrome.

To study correlation among number(n), diameter (D), and blood reflux time(t) and the left common iliac vein stenosis degree of the expansion of perforating veins, so as to guide the clinical formulation and adjust the treatment plan. Retrospective analysis of 45 PVs patients with left common iliac vein in different degrees of compression in our hospital from 2010 to 2012 was performed. Left common iliac vein was divided into 50%-69%, 70%-99%, 30%-49% and occlusion of the stenosis to avoid the error of the left iliac vein stenosis. Pearson's correlation analysis among the number, diameter, and blood reflux time of perforating veins and left common iliac vein was performed. Pearson's correlation analysis among the number, diameter, and blood back flow time of perforating veins, and the degree of stenosis was performed, and these results showed that correlation coefficients among the number, diameter, and blood return the PVs between flow time and the degree of stenosis were rp-n=0.784, rp-d=0.893, rp-t=0.845 (P<.001), respectively. The two variables exist positive correlation and correlation was significant. With the increase in left common iliac vein stenosis, the number of perforating veins and the diameter increased, and the time of blood flow were prolonged.

Venous Ulcer: Could Endovenous Radiofrequency Ablation Improve Ulcer Healing? Preliminary Results of a Randomized Controlled Trial

Venous leg ulcers can take several weeks or months to heal and typically present with repeated cycles of ulceration, healing, and recurrence that result in high treatment costs and have a negative impact on patients’ quality of life. The multicomponent compression bandage system is still regarded as the “gold standard” to treat venous ulceration since previous randomized controlled trials failed to show improvement in ulcer healing rates by venous insufficiency surgical treatment despite decrease of ulcer recurrence risk. The current study was designed to investigate whether radiofrequency endovenous ablation of saphenous and perforating insufficient veins could increase venous ulcer healing rates. We did a prospective, controlled, randomized, open-label trial at a single center in Brazil. Participants had venous leg ulcer related to saphenous and perforating vein insufficiency with no sign of current or previous deep venous thrombosis. We randomly assigned participants to receive a weekly-changed two-layer compression bandage system alone or surgical radiofrequency ablation of insufficient saphenous and perforating veins before starting to receive the same compression system. Participants were stratified by ulcer duration (>6 months or <6 months) and ulcer area (>5 cm2 or <5 cm2). The primary end points were ulcer healing rates 6, 12, and 24 weeks after start of treatment. From January 2015 to August 2017, there were 77 patients considered eligible for the study, but 21 participants were excluded before randomization because of treatment abandonment, pretreatment wound healing, ultrasound evidence of previous unknown deep venous thrombosis, and clinical deterioration. The 56 remaining patients were randomly allocated to two treatment groups: 29 to multicomponent compression bandage alone and 27 to combined surgical and compressive treatment. The study is still ongoing, and 24 patients have been under intervention. We have therefore considered for analysis 15 participants from the surgical group and 17 participants from the isolated compressive treatment group. There are no statistically significant differences between groups in ulcer healing rates after 6 weeks. However, after 12 weeks, 73% of surgically treated patients have their ulcers healed vs 65% of compression alone-treated patients (hazard ratio, 4.968; 95% confidence interval, 1.053-23.42; P = .043). After 24 weeks, ulcer healing rate differences are even more evident (100% vs 76%), with the chance of healing greater for the surgical group (hazard ratio, 6.278; 95% confidence interval, 1.693-23.28; P = .006). Until now, 12- and 24-week venous ulcer healing rates were significantly greater in participants treated by endovenous radiofrequency ablation of saphenous and perforating veins plus two-layer compressive bandages than in patients who were treated with compression alone. We expect this difference to be maintained until the end of the study.

Endovenous Laser Ablation in Patients with Venous Ulcers: Long Term Results and Risk Factors for Non-healing or Recurrence

Introduction: The ESCHAR study showed that superficial venous surgery reduced the recurrence rate compared with compression therapy only. Ulcer recurrence rates after endovenous laser (EVL) treatment for superficial venous insufficiency seem comparable, but so far only small groups and shorter follow up times have been reported. The aim of this study was to investigate long term treatment outcomes of patients with venous ulcers treated with EVL in a larger population, in ordinary clinical practice without dedicated ulcer care. Methods: One hundred and ninety seven consecutive patients previously treated with EVL for a healed or open venous ulcer were invited to follow up including clinical examination, quality of life score using EQ5D, Duplex, ankle brachial index, venous refilling time (RT) and pump volume measured with PPG. Risk factors for non-healing and/or recurrence were calculated using chi-square to compare proportions and logistic regression. Results: 197 patients have been examined after a mean follow up time of 41 months. After EVL further ulcer treatment and compression was carried out mostly in primary care. Details of post-operative treatment were not possible to retrieve. 165 patients had healed ulcers (Group 1) without recurrence during follow up, 32 patients never healed or had a recurrence after EVL (Group 2). The mean age was 62.7 years for group 1 and 64,2 for group 2 (NS). The number of women/men was 99/66 in group 1 and 14/18 in group 2 (NS). Significant risk factors for non-healing and or recurrence were reduced ankle mobility (p = .009), perforating vein insufficiency (PVI) in the ulcer area (p = .007), popliteal and crural vein insufficiency (p = .016 and .000 respectively) and shortened RT (p = .016). There was a greater proportion in group 2 with previous deep venous thrombosis, diabetes, remnant varicose veins (VV) in ulcer area, and they had lower QoL, but no significance was reached. Other non-significant risk factors were cardiovascular disease, previous VV surgery, smoking, C5 or C6 at EVL, skin disease and remnant VV outside ulcer area. Conclusion: Endovenous laser ablation treating patients with venous ulcers in ordinary clinical practice confers long-term healing in a majority. Non-healing and recurrence was associated with reduced ankle mobility, deep and perforating vein insufficiency and shortened RT. It may be speculated that healing rates can be further improved with a more dedicated ulcer care and follow up post-operatively.

Recurrent varicose veins after surgery: an analysis of 247 patients

Background: This study aims to investigate the reasons for postoperative recurrence of varicose veins and anatomical distribution of recurrent venous insufficiency using ultrasonographic and venographic findings. Methods: A total of 285 legs of 247 consecutive patients who were reoperated due to recurrent varicose veins were retrospectively analyzed. Data were evaluated in terms of clinical characteristics of the patients, symptoms, and vascular imaging methods. Results: A total of 245 legs (86%) showed perforating vein insufficiency, while 213 (75%) showed reflux of the superficial femoral vein of varying degrees of severity. Residual saphenous vein was recorded in 183 legs (64%), while 11 (4%) legs had iliac vein thrombosis due to previous post-thrombotic syndrome. Conclusion: Recurrence after varicose vein surgery is multifactorial. As well as unmodifiable factors including age, sex, genetic susceptibility and occupation, inadequate preoperative imaging, limited experience of the surgeon or incomplete surgical intervention and neovascularization during the postoperative period are responsible for the recurrence of varicose veins after the primary surgery. Prevention of varicose vein recurrence after surgical intervention requires a more effective use of preoperative imaging modalities and the best surgical intervention must be planned for each patient before surgery based on the results obtained.

Analysis of a Series of Patients with Varicose Vein Recurrence

Varicose veins of the lower extremities is a common clinical condition. Although surgical treatment is often successful, the recurrence rate remains high. This retrospective study evaluated the reasons for postoperative recurrence of varicose veins by analysing ultrasonography and venography findings in patients with recurrent disease. A series of consecutive cases of recurrent varicose veins of the lower limbs was reviewed. Data collected included clinical characteristics, symptoms and vascular imaging. The study included 109 legs with recurrent varicose veins (92 patients): 101/109 legs (92.7%) showed perforating vein insufficiency and 86/109 (78.9%) showed reflux of the superficial femoral vein, of varying degrees of severity. Residual saphenous vein was recorded for 82 legs (75.2%), while 19 (17.4%) had blocked iliac veins due to post-thrombotic syndrome. Several factors that may contribute to varicose vein recurrence have been identified. These include failure to ligate perforating veins and initial failure to perform the appropriate surgical intervention. Prevention of varicose vein recurrence after surgical correction requires a more extensive use of preoperative imaging, to tailor surgical intervention to suit individual patients.

Endovenous Laser Ablation and Concomitant Foam Sclerotherapy: Experience in 504 Patients

To investigate the value of endovenous laser ablation (ELA) and concomitant ultrasound-guided foam sclerotherapy (USGFS) in patients with chronic venous insufficiency. During a 6-year period, concomitant USGFS of the varicose veins were performed in 504 out of 610 patients who underwent ELA for truncal or perforating vein insufficiency. In these 504 patients (944 legs; bilateral in 440 patients), the incompetent veins were greater saphenous vein in 615 legs, small saphenous vein in 118 veins, perforating veins in 42 legs, and a combination of these in 169 legs. In all patients, after ELA of the incompetent veins, USGFS was performed for the remaining varicosities with 1-3% polidocanol foam. Patients were followed up clinically and with color Doppler ultrasound at 1, 6, and 12months. ELA was technically successful in all cases, although another venous puncture was necessary in 29 legs. Concomitant USGFS was also technically successful in all cases, but one to three additional sclerotherapy sessions were performed in 203 legs with persistent varicosities. During the follow-up, recanalization of the laser-ablated refluxing veins occurred in 16 legs (1.7%) and was treated with repeat ELA or USGFS. Major complications occurred in 1.4% of the treated legs and included skin necrosis and calf vein thrombosis. ELA and concomitant foam sclerotherapy is feasible and effective. The procedures are associated with a low complication rate and can be performed in both legs in the same session. Concomitant use of laser and foam may potentially decrease the recanalization rate of laser-ablated vessels.

Endovenous laser ablation and foam sclerotherapy for varicose veins: does the presence of perforating vein insufficiency affect the treatment outcome?

Superficial venous insufficiency is a common problem associated with varicose veins. Endovenous laser ablation (EVLA) and concomitant ultrasound (US)-guided foam sclerotherapy are recent treatment methods alternative to surgery in the treatment of superficial venous insufficiency. To compare the effectiveness of EVLA and concomitant US-guided foam sclerotherapy prospectively in two different subgroups of the disease (isolated truncal vs. truncal with perforating vein insufficiency). The study was approved by the institutional review board. Fifty-five patients with symptomatic saphenous vein insufficiency and varicose veins were included in the study. Seventy-three EVLA and concomitant foam sclerotherapy were performed for 60 lower extremities. To determine the severity of the venous disease, Venous Clinical Severity Score (VCSS) and Visual Analogue Scale (VAS) were carried out before and 6 months after the treatment. Patients were followed up clinically and with Doppler ultrasonography for 6 months after the procedures. At the sixth month of the follow-up; the total occlusion rate for the saphenous veins was 98.64% (72/73), and re-canalization rate was 1.36% (1/73). The total occlusion rate for the perforating veins was 75% (18/24), re-canalization rate was 25% (6/24). There was no notable major complication. VCSS and VAS scores were decreased significantly following the treatment (p < 0.05). The patients who had isolated saphenous vein insufficiency (Group I: 36/60) and those who had saphenous and perforating vein reflux (Group II: 24/60) were compared. VAS scores were more prominently decreased after the treatment in the isolated saphenous vein insufficiency group (p < 0.05). VCSS were also decreased more prominently in Group I when compared to Group II. EVLA and concomitant US-guided foam sclerotherapy are effective, safe, and minimally invasive treatment options, yielding good cosmetic and clinical results in both isolated truncal and truncal with perforating vein insufficiency groups. However, clinical results and satisfaction of the patients were remarkably superior in cases with isolated truncal vein insufficiency compared to truncal and perforating vein insufficiency.

Patterns of Venous Insufficiency after an Acute Deep Vein Thrombosis

The purpose of this study was to investigate patterns of venous insufficiency during a 12-month period after an acute deep vein thrombosis. Seventy limbs in 67 patients with an acute deep vein thrombosis (DVT) involving 147 anatomic segments were evaluated with duplex scanning at 1 month, 3 months, 6 months, and 1 year. Venous segments were examined whether they were occluded, partially recanalized, or totally recanalized, and the development of venous reflux was evaluated. The segments investigated were the common femoral vein (38 segments), femoral vein (33 segments), popliteal vein (36 segments), and calf veins (40 segments). There were 35 limbs with isolated DVT and the remaining 35 had multisegment DVT. At 1 year, thrombi had fully resolved in 76% of the segments, 20% remained partially recanalized, and 5% were occluded. The venous occlusion was most predominant in the femoral vein (21%) at 1 year. On the contrary, rapid recanalization was obtained in calf veins than in proximal veins at each examination (p < 0.01). Deep vein insufficiency was detected as early as 1 month after development of DVT, and the reflux was most predominant in popliteal veins (56%), followed by femoral veins (18%). No reflux was found in calf veins. Multisegment DVTs had a significantly higher incidence of deep vein insufficiency than single segment DVTs at 1 year. Development of superficial venous insufficiency was found in 5 limbs (7%) and perforating vein insufficiency in 5 (7%). Lower extremity venous segments showed different proportions of occlusion, partial recanalization, and total recanalization. Calf veins showed more rapid recanalization than proximal veins. Venous reflux was noted as early as 1 month. The limbs involving multisegment DVTs on initial examination had a higher incidence of deep vein insufficiency and could require much longer followup studies.