Primary Deep Venous Insufficiency Research Articles

Perivascular Administration of Hyaluran-Cyanoacrylate Complex Gel for Deep Venous Reflux

Objective: Deep venous insufficiency is an important health issue affecting the population worldwide. In this study we aimed to assess the effectiveness and safety of a novel antireflux treatment procedure in patients with primary deep vein insufficiency.
 Methods: Between October 2016 and December 2018, 81 valvular leak operations consisting of perivenous hard gel injection were performed in 81 patients with primary deep venous insufficiency. The clinical symptoms of the patients were between C3-C6 according to the CEAP clinical classification. Venous insufficiency associated with only one deep venous valve was verified with Doppler ultrasonography. Patients were assessed with physical and ultrasound examination on the follow-up visits, which were achieved on the third day and at the first, sixth, and twelfth months. The nonexistence of reflux in the treated valve level was defined as the success of the procedure. Any reflux, which lasted 0.5 seconds or more, was regarded as a lack of success.
 Results: The ages of the patients ranged between 32 and 78. All the patients had deep venous insufficiency. The follow-up could be achieved in all the patients. The mean volume of the gel administered was 2.4±0.9 ml. The mean procedure duration was 22.3±8.9 (range 14–42) minutes. The procedures could be performed successfully in all of the patients confirmed perioperatively and on the third day of follow-up with the elimination of reflux. The sixth-month follow-up, with the same vein diameter after the treatment without any reflux, revealed the same findings as to the first-month follow-up. The treatment was not associated with any significant morbidity or mortality. The VCSS decreased significantly when preprocedural and twelfth-month VCSS were compared as 21.8 ± 4.8 and 3.8±0.7, respectively (p

A Retrospective Study of Deep Vein Insufficiency Treatment Device: ICT.

Objective: This study aimed to evaluate the efficacy and safety of a newly developed, leak closure Internal Compression Therapy (ICT) (Invamed, Ankara, Turkey) device during a single-session procedure in a group of patients with primary deep valve incompetence.Methods: There were 286 patients who were diagnosed with deep venous reflux by duplex scanning. They underwent valvular leak operations to treat primary deep venous insufficiency. Follow-up visits were on the third day, first month, sixth month and twelfth month. At each visit, duplex scanning and a clinical examination were performed. Successful treatment was defined as deep vein valves without reflux. Any patency or reflux over 1 sec was considered a failure.Results: The study enrolled 286 patients with deep venous insufficiency. Procedural technical success was 100%. At the one-year follow-up, the overall success, among all patients, was 92%. No significant morbidity or mortality related to the procedure were observed. All patients had major improvements in venous clinical severity score (VCSS) scores postoperatively. VCSS scores at pre-intervention, and at the twelfth month, were 20.7±5.9 and 3.9±0.9, respectively (p<0.001).Conclusion: After the twelve-month follow-up, the postprocedural outcomes indicate the ICT device is safe and effective.

Application of colour Doppler in encircling constriction of the superficial femoral vein in primary deep venous insufficiency of the lower limbs

1. The aim of the present study was to evaluate the clinical value of colour Doppler application in encircling constriction of the superficial femoral vein in deep vein insufficiency. 2. A total of 87 patients with primary deep venous insufficiency (PDVI) using ascending venography were randomly divided into group A (44 patients) and group B (43 patients). All patients underwent encircling constriction of the superficial femoral vein, high ligation and ablation of the great saphenous vein and perforator vein. The duration of venous reflux at operation was monitored with colour Doppler in group A (but not group B) to evaluate the immediate effects. Clinical grading and scoring of the clinical, etiological, anatomical, pathophysiological (CEAP) classification system were used to evaluate the follow-up curative effect. 3. In four cases from group A, completely destroyed valves were identified at the time of operation and autografting of the vein segment with a valve was carried out. The intraoperative examination of colour Doppler in group A showed a much shorter duration of vein reflux after the encircling constriction procedure than the presurgery condition. According to the results of CEAP grading, the success rate of group A (95.0%, 38/40) was significantly higher than that of group B (76.7%, 33/43). Postoperative clinical scores were markedly lower than preoperative scores in both groups A and B. 4. In conclusion, our data suggest that application of colour Doppler in encircling constriction of superficial femoral vein might enhance surgical pertinence and improve surgical effect for PDVI.

Chronische venöse Insuffizienz bei postthrombotischem Syndrom und Varikose

Venous disorders have a high prevalence and require approximately 1% of health budgets of industrialized countries. The postthrombotic syndrome (PTS) is defined by subjective symptoms and morphologic trophical skin changes following deep venous thrombosis. Prevention of venous thromboembolism in risk situations, easy availability of diagnostic tools (D-dimers, colour-coded duplex sonography) and early detection of deep venous thrombosis, as well as immediate therapeutic anticoagulation along with leg compression during the acute phase and over a two year period of time significantly reduce the incidence of PTS. Chronic venous insufficiency (CVI) includes trophical skin and soft tissue pathologies of the lower leg due to venous hypertension in the distal venous system of the lower extremity. Roughly, two main causes can be distinguished. (A) Deep venous insufficiency (A1 in postthrombotic syndrome; A2 in primary deep venous insufficiency) and (B) superficial venous reflux, usually varicose veins. Compression therapy, surgical ablation of superficial venous reflux, and tangential ablation with split skin graft (shave treatment) of refractory venous ulcers are the mainstays in the treatment of CVI.

Deep venous external valvuloplasty using a rigid angioscope

The aim of this study was to evaluate the long-term results of deep venous valvuloplasty using a rigid metal angioscope. Forty patients who underwent deep venous external valvuloplasty using a rigid metal angioscope for primary deep venous insufficiency were enrolled. The preoperative CEAP (Clinical/Etiology/Anatomy/Pathophysiology) classifications were class 2 in 13 patients, class 3 in 8 patients, class 4 in 12 patients, class 5 in 1 patient, and class 6 in 6 patients. In 9 legs in 6 patients, the valves were either destroyed or congenitally absent, and deep venous plication was applied instead. The long-term operative results were evaluated from clinical charts and direct telephone interviews. During a mean follow-up period of 5.0 years, we experienced no deep vein thromboses or other complications. In 39 of the 40 patients, the subjective symptoms improved. The improvement after successful valvuloplasty was 82% with respect to the CEAP classification. Among the 9 legs treated by deep venous plication alone, 5 had improved CEAP classifications, while 4 showed no change. Deep venous external valvuloplasty assisted by a rigid angioscope is a safe and effective method for severe valve insufficiency. Furthermore, the long-term results are positive. Deep venous plication may therefore represent an effective alternative for patients who cannot undergo valvuloplasty.

Endovenous laser treatment combined with a surgical strategy for treatment of venous insufficiency in lower extremity: A report of 208 cases

We assessed the safety and efficacy of endovenous laser treatment (EVLT) of the saphenous vein combined with a surgical strategy for treatment of deep venous insufficiency in the lower extremity. Two hundred thirty venous insufficiencies of the lower limbs in 208 consecutive patients (93 men and 115 women; mean age, 54.15 years) were treated with EVLT combined with surgical strategies. All patients were symptomatic. There were 84 limbs (36.5%) in C(2), 25 (10.9%) in C(3), 109 (47.7%) in C(4), 1 (0.4%) in C(5), and 9 (3.9%) in C(6) (CEAP), and Klippel-Trenaunay syndrome was present in 2 limbs. A total of 119 (51.7%) had perforator vein incompetence. Four therapeutic methods were included in this series according to symptoms, CEAP classification, and venous reflux. Simple EVLT was performed for 15 patients with only great saphenous vein (GSV) incompetence or Klippel-Trenaunay syndrome in 19 lower limbs. EVLT combined with high ligation of the GSV and open ligation of perforators was performed for 5 patients with GSV and perforator incompetence in 5 lower limbs. EVLT was combined with high ligation of the GSV for 76 patients with GSV incompetence in 94 lower limbs. EVLT was combined with external banding of the first femoral venous valve and high ligation of the GSV for 112 patients with primary deep venous insufficiency in 112 lower limbs. All patients were followed up on an outpatient basis for physical examinations and postoperative complaints, and duplex ultrasonography was performed 2 weeks, 6 months, and 1 year after operation. All patients tolerated the procedure well and returned to normal daily activities immediately, achieving a 100% immediate clinical success rate. Spot skin burn injuries occurred in 2 patients (1.0%). Paresthesia in the gaiter area was noted in 15 patients (7.2%). No postprocedural symptomatic deep venous thrombosis or pulmonary embolism occurred. Three patients had local recurrent varicose veins in the calf (1.4%) during a 2- to 27-month follow-up (mean, 6.12 months). Postoperative clinical classes were significantly improved between 2 weeks and 24 months (P = .0001 at 2 weeks and 3 to 18 months; P = .0055 at 24 months compared with before operation), especially in preoperative C(2) to C(3) stage patients, who achieved complete amelioration. EVLT is a novel minimally invasive treatment with advantages of safety, effectiveness, and simplicity, and it leaves no scars. Its indications can be expanded by combining EVLT with surgical strategies.

The evaluation for the therapeutic effect and the clinical practicability of encircling constriction of superficial femoral vein in the treatment of primary deep venous insufficiency

To evaluate the therapeutic effect and the clinical practicability of encircling constriction of superficial femoral vein in the treatment of primary deep venous insufficiency (PDVI). Ninety-seven limbs in 97 patients who were proved to be PDVI by ascending venography were divided into Group A (79 limbs) and Group B (18 limbs). Patients of Group A were treated with the encircling constriction of venous wall at the first valve of superficial femoral veins. And they were also treated with the high ligation and ablation of great saphenous vein, ablation of superficial veins and ligation of perforator veins at the same time. Patients of Group B were simply treated with the high ligation and ablation of great saphenous vein, ablation of superficial veins and ligation of perforator veins. Ascending venography and CEAP classification and clinical scoring were proceeded from two months to six years after operation to evaluate the effect of the operation. The difference between preoperative and postoperative scores of Group A and Group B were both remarkable (Group A, P < 0.01; Group B, P < 0.05). The difference of scores, which equated to preoperative scores minus postoperative score, between Group A and Group B were also prominent (P < 0.01). Post-operation ascending venography was performed on 67 limbs in Group A. The effective rate of the operation is 83.58% (28 + 28/67), obviously effective rate is 41.79% (28/67). Same exam was performed on 12 limbs in Group B and the effective rate of the operation is 33.33%. The difference between two groups' effective rate is significant (P < 0.05). Clinical scoring of Group A decreased much more than Group B; The effective rate of Group A in ascending venography is also much higher than Group B. Encircling constriction of superficial femoral vein is useful to relief the symptom and recover the shape and function of the valve of superficial femoral veins. Those who are diagnosed to be PDVI by means of pre-operation ascending venography and Valsalva test should accept the operation of the encircling constriction of superficial femoral vein.

Surgical treatments for chronic deep venous insufficiency

Objective: The aim of this study was to critically appraise and synthesize the published evidence regarding the short- and long-term efficacy/effectiveness of surgical techniques for patients with deep venous insufficiency (DVI) refractory to other forms of management. Methods: All original, published studies on non-pregnant human patients undergoing treatment for deep or mixed deep/superficial/perforator chronic venous insufficiency were identified by systematically searching PubMed, EMBASE, CINAHL, The Cochrane Library, Science Citation Index and the websites of various health technology assessment agencies, research registers and guidelines sites, from January 1990 to July 2003. No language restriction was applied. Results: A total of two randomized controlled trials and 12 non-randomized comparative studies reported on a variety of procedures ranging from superficial venous surgery (SVS) and subfascial endoscopic perforator surgery (SEPS), through to deep venous reconstruction (including valvuloplasty, transplantation and transposition) for the treatment of DVI. Limited evidence suggested that combined SVS/valvuloplasty is a relatively safe procedure that is potentially more effective than SVS alone in preventing ulcer recurrence in patients with primary DVI in both the short- and mid-term. Evidence for the efficacy of valvuloplasty, bypass, transplantation, SEPS and iliac stenting in the treatment of DVI was inconclusive. The optimal surgery for patients with deep venous obstruction or secondary valvular incompetence remains unclear. Conclusions: It is unlikely that a large randomized, or even non-randomized, controlled trial will be conducted to ascertain the safety and efficacy of surgery for DVI. However, standardized reporting and collection of data in a registry would be a move forward. In addition, professional bodies should consider providing guidance, in the form of an evidence-based treatment algorithm, that would define when to perform SVS in patients with mixed or deep venous insufficiency and what type of deep venous surgery is considered appropriate for different indications. A prime focus of future research may be to understand why less invasive treatments have failed in patients requiring surgery for DVI and to identify those patients who would benefit most from early surgical intervention.

Insuffisance valvulaire non post-thrombotique du système veineux profond des membres inférieurs

Although deep non post-thrombotic venous reflux in the lower limbs has been identified for several decades, it remains poorly recognized as a pathophysiological mechanism responsible for chronic venous disease. Primary deep venous insufficiency which is the most frequently observed type is combined with primary superficial venous insufficiency in about 15% of varicosities, and may be responsible for recurrences after their treatment. In severe cases, in case of conservative treatment failure, surgery, mainly valvuloplasty, must be considered after full investigations including duplex scan, ambulatory venous pressure measurement and phlebography.

Results of Valvuloplasty in Patients Presenting Deep Venous Insufficiency and Recurring Ulceration

The purpose of this retrospective study was to assess mid-term results of valvuloplasty in patients presenting chronic recurring venous stasis ulceration. From 1988 to 1993, valvuloplasty was performed in the superficial femoral vein of 33 lower extremities in 28 patients presenting recurring ulceration. In 23 cases, previous surgery in the superficial venous system or perforating vein had failed. Preoperative work-up demonstrated primary deep venous insufficiency (PDVI) in 22 extremities (group I), proximal PDVI in association with distal postthrombotic syndrome (PTS) in 10 (group II), and Klippel-Trenaunay syndrome in 1. Hemodynamic assessment with tourniquet placement demonstrated a mean venous return time of 9 sec (+10, -8). Descending femoral phlebography showed Kistner grade 4 in 30 cases. Outcome was evaluated by clinical examination and Dupplex scan with photophlethysmography at follow-up times ranging from 2 to 7.6 years (mean: 51 months). Correlation between outcome of valvuloplasty and clinical findings was excellent. The incidence of poor clinical and hemodynamic results was higher for patients with PTS. Valve repair in association with surgery for superficial vein insufficiency and ligation of perforators gives good results in patients with isolated PDVI.

Angioscopy-Assisted Valvuloplasty for Primary Deep Venous Valvular Insufficiency

Primary deep venous valvular insufficiency causes reflux syndrome. Angioscopy permits the surgeon not only to ascertain that venous valves have not been destroyed but to perform external valvuloplasty under visual control with the valves under pressure. We have performed angioscopy-assisted venous valvuloplasty in three men (mean age 36 years; range 30 to 38 years) and one woman (age 58 years). All four patients had class 3 disease (SVS/ISCVS classification). Descending phlebograms showed grade 3 reflux in one patient and grade 4 reflux in three patients. In all patients angioscopy-assisted valvuloplasty of the superficial femoral vein was combined with wrapping with a segment of polytetrafluoroethylene prosthesis, stripping of incompetent superficial veins, and subfascial ligation of perforating veins. Mean follow-up was 12 months (range 6 to 17 months). In three patients ulcers healed and did not recur; in the remaining patient nearly complete healing was obtained after skin grafting. In all patients ambulatory venous blood pressure improved significantly and venous filling time returned to normal (> 15 seconds). At duplex ultrasonography and descending phlebography, no residual reflux was demonstrated. At final follow-up, all repaired valves were patent and competent. Our experience demonstrates that angioscopy-assisted venous valvuloplasty combines the accuracy of valvuloplasty by means of phlebotomy and the simplicity of external valvuloplasty and thus is preferred to either of these methods.

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.

The Role of External Banding Valvuloplasty with the Venocuff in the Treatment of Primary Deep Venous Insufficiency

Objective: Evaluation of the role of external banding valvuloplasty in the treatment of primary deep venous insufficiency. Design: Retrospective analysis of patients subjected to external banding valvuloplasty (EBV) with the Venocuff in relation to the evolution of venous reflux. Setting: Department of Vascular Surgery, Instituto Dermopatico dell'Immacolata, Rome, Italy. Patients: Ten patients with signs and symptoms of chronic venous insufficiency. Interventions: Application of a Venocuff to the superficial femoral vein. Main outcome measures: The correction rate of the primary deep venous reflux assessed by venography and colour duplex ultrasound. Results: In a mean follow-up period of 10 months, deep vein reflux was completely abolished in nine patients (90%). Conclusions: The Venocuff is an improvement over the previous techniques, of surgical treatment of primary deep venous insufficiency in reducing the dilated valve bulb to the correct size in a quick, standardized and precise way.