Saphenofemoral Junction Incompetence Research Articles

Endovenous Laser Treatment of Saphenous Vein Reflux: Long-Term Results

To report long-term follow-up results of endovenous laser treatment for great saphenous vein (GSV) reflux caused by saphenofemoral junction (SFJ) incompetence. Four hundred ninety-nine GSVs in 423 subjects with varicose veins were treated over a 3-year period with 810-nm diode laser energy delivered percutaneously into the GSV via a 600- micro m fiber. Tumescent anesthesia (100-200 mL of 0.2% lidocaine) was delivered perivenously under ultrasound (US) guidance. Patients were evaluated clinically and with duplex US at 1 week, 1 month, 3 months, 6 months, 1 year, and yearly thereafter to assess treatment efficacy and adverse reactions. Compression sclerotherapy was performed in nearly all patients at follow-up for treatment of associated tributary varicose veins and secondary telangiectasia. Successful occlusion of the GSV, defined as absence of flow on color Doppler imaging, was noted in 490 of 499 GSVs (98.2%) after initial treatment. One hundred thirteen of 121 limbs (93.4%) followed for 2 years have remained closed, with the treated portions of the GSVs not visible on duplex imaging. Of note, all recurrences have occurred before 9 months, with the majority noted before 3 months. Bruising was noted in 24% of patients and tightness along the course of the treated vein was present in 90% of limbs. There have been no skin burns, paresthesias, or cases of deep vein thrombosis. Long-term results available in 499 limbs treated with endovenous laser demonstrate a recurrence rate of less than 7% at 2-year follow-up. These results are comparable or superior to those reported for the other options available for treatment of GSV reflux, including surgery, US-guided sclerotherapy, and radiofrequency ablation. Endovenous laser appears to offer these benefits with lower rates of complication and avoidance of general anesthesia.

Compression sclerotherapy of anterolateral thigh primary varicose veins (lateral accessory saphenous varicose veins): a prospective five-year follow-up study

Aim: To determine the percentage of varicose vein recurrence after compression sclerotherapy of a specific primary varicose vein, the anterolateral thigh vein (lateral accessory saphenous vein), without saphenofemoral junction (SFJ) incompetence at yearly intervals in a long-term follow-up study, and to investigate factors influencing recurrence. Patients and methods: Of 117 patients recruited, 11 were lost to follow up; therefore 106 patients were evaluated: 97 women, mean age 42 years (range 21-72) and nine men, mean age 47 years (range 21-67). If SFJ incompetence was present, surgical ligation of the junction was performed. Primary varicose veins were treated with compression sclerotherapy using polidocanol. A total of 111 limbs were studied. Results: Recurrent varicose veins were found after six months in 6% of cases, after one year in 18% (cumulative percentage), after two years in 28%, after three years in 36%, after four years in 46%and after five years in 54%. No differences could be detected between the recurrence group and the group without recurrence regarding length of varicose veins, amount of polidocanol used, number of injections, circumference of the leg or age of the patient. The varicose vein diameter was significantly larger in the recurrence group. Conclusions: Compression sclerotherapy with polidocanol of the anterolateral thigh vein (lateral accessory saphenous vein) without SFJ incompetence results in a high recurrence rate. Recurrence depends only on the vessel diameter, and not on the length of the varicose vein, amount of sclerosant used or patient age.

Whole-leg duplex mapping for varicose veins: Observations on patterns of reflux in recurrent and primary legs, with clinical correlation

Background: the variability of venous reflux patterns complicate the management of venous disease. Our study investigates specific variations in venous anatomy and patterns of reflux in varying clinical situations. Methods: prospective analysis of 464 legs in 355 patients was performed by complete duplex venous mapping of both primary and recurrent varicose veins. Hand Held Doppler (HHD) and Duplex Ultrasonography (Duplex US) observations in the popliteal fossa were compared in a subgroup of 89 patients with primary varicose veins. Distribution of venous system disease was correlated with clinical severity in a subgroup of 117 affected legs which was representative of the overall study group. Results: sapheno-femoral junction (SFJ) incompetence predominated in both primary and recurrent varicose veins. Only 21% of primary legs and 25% of recurrent legs had sapheno-popliteal junction (SPJ) incompetence. SPJ incompetence was present in only 42% of cases where reflux in the popliteal region on HHD had been demonstrated. A proportion of both primary and recurrent varicose veins had evidence of deep venous incompetence (DVI). Sixty-four percent of primary leg ulcer patients had superficial incompetence alone. In patients with recurrent varicosities and ulceration, 57% had SPJ incompetence, 64% multiple sites and 50% DVI. Conclusion: the complex variations of varicose vein anatomy and functional pathology in the lower limb are currently best assessed by complete whole-leg venous duplex mapping.Eur J Vasc Endovasc Surg 25, 267–275 (2003)

Primary varicose veins: The sapheno-femoral junction, distribution of varicosities and patterns of incompetence

Objective: to determine the patterns of long saphenous vein (LSV) disease in primary varicose veins (VVs). Design: a retrospective analysis of venous duplex scans performed on patients referred for treatment of primary VVs. Methods: analysis was made of sapheno-femoral junction (SFJ) incompetence, non-SFJ incompetence, segmental and perforating vein incompetence, distribution of varicosities, deep venous insufficiency, and short saphenous incompetence. Results: four hundred and eighty-one patients were assessed (median age 50 (range 12–98) years; male:female ratio 1:1.95), comprising 706 limbs. Forty-six per cent of limbs had a competent SFJ, 64% of which had no incompetent perforating vessels associated. Disease was more widespread when the SFJ was incompetent. Varicosities were most common in the calf, occurring at or below the level of incompetence within the LSV. Incompetent segments occurred most commonly above-knee. There was no obvious correlation between incompetent perforators and distribution of varicosities, or incompetent segments. Short saphenous incompetence and non-SFJ groin recurrence were associated more with a competent SFJ, the converse being true for the Giacomini vein. Conclusion: primary VVs develop in isolated segments of the superficial venous system (without connection to the deep system) at, or distal to, the underlying main trunk incompetence, suggesting a process of “spreading incompetence” from one focal point, producing varicosities (mainly in tributaries).Eur J Vasc Endovasc Surg 25, 53–59 (2003)

Causes of re-recurrence after polytetrafluoroethylene patch saphenoplasty for recurrent varicose veins

The aim of this study was to determine whether a polytetrafluoroethylene (PTFE) patch sutured over the religated saphenofemoral junction could reduce the rate of recurrence after operation for recurrent varicose veins. Fifty patients who had surgery for recurrent long saphenous incompetence (81 legs had a small PTFE patch sutured over the religated saphenofemoral junction. There were no major complications following surgery. Three patients had a wound infection or delayed healing. All patients were invited for clinical examination and duplex imaging at a median of 19 (range 6-39) months after operation. Some 38 of 43 patients (70 legs) remained satisfied with the results of surgery; 16 (23 per cent) of 70 legs had visible veins on inspection and eight of these (11 per cent) involved symptomatic recurrence. Duplex imaging showed that recurrence was due to saphenofemoral junction incompetence in ten legs; two appeared to have a major groin connection but the other eight appeared to have neovascularization. Other causes were thigh perforator reflux (three legs) and cross-groin collaterals (three). Eleven of the 16 legs with recurrence had varicography but in two the procedure was a technical failure. Two legs had evidence of a significant connection (more than 3 mm) and two a minor connection (less than 3 mm) to the femoral vein at the level of the PTFE patch, but in the remainder recurrence was due to upper thigh perforating veins. There was good concordance between duplex imaging and varicography. PTFE patch saphenoplasty appears to be safe. Although these are early results, the technique seems potentially as effective as other barrier methods that have been investigated; in ten legs (12 per cent) recurrence was attributed to failure at the level of the PTFE patch.

Efficacy of the comprehensive objective mapping, precise image guided injection, Anti-reflux positioning and sequential sclerotherapy (compass) technique in the management of greater saphenous varicosities with saphenofemoral incompetence

Objective:To evaluate the efficacy of the COMPASS technique in the management of greater saphenous varicosities with saphenofemoral incompetence.Design:Prospective open trial (2-6 year follow-up).Patients:One hundred and eighty-six limbs with refluxing greater saphenous vein (5.4–25.4 mm) and incompetent saphenofemoral junction (6.1–31.3 mm).Main outcome measure:Obliteration, recanalisation, residual veins, neovascularisation, venous dysfunction score.Results:Greater saphenous varicosity is commonly a disease of individuals in their forties, with morbid clinical presentations. Three stages of the COMPASS technique achieved 100% and 98% obliteration of the saphenofemoral junction and greater saphenous vein respectively. There was significant improvement in the venous dysfunction score. Residual refluxing veins were easily managed by sequential treatment. The results are sustained in the 3.4 SD 1.7 year follow up. There was no serious adverse experience reported.Conclusion:The COMPASS technique is safe and ...

The treatment of varicose veins with external stenting to the saphenofemoral junction.

Presented are the experiences with 1,516 external valvular stents (Venocufft and Venocuff II) implanted at the saphenofemoral junction (SFJ) between 1985 and 2000. To assess the applicability of the procedure it was found that the appropriate implantation was performed in 34% of 310 consecutive venous procedures. To assess patient preference between external valvular stenting and simultaneous contralateral stripping, 56 consecutive patients were followed up at 3 months postoperatively. Four percent preferred stripping, 4% had no preference, and 92% preferred Venocuff IItrade mark implantation. Competence at the SFJ with specific duplex ultrasound indicators was 94% at 3 months (n = 100) and 90% at 4.8 years (n = 107). Minimal residual reflux (less than 50 mL/minute with maximum Valsalva) was present in the remainder but did not produce symptoms and very rarely progressed over the mean time of 5 years. The internal diameter (ID) of the long saphenous vein (LSV), 3 cm distal to the SFJ, changed from 7.6 +/- 2.3 mm to 4.9 +/- 1.1 mm (p < 0.001) and at the knee from 6.9 +/- 1.9 mm to 3.7 +/- 1.0 mm (p < 0.001). Patients presenting with underlying deep venous disease began with significantly higher ID, ie, 9.0 +/- 2.1 mm at the upper end of the LSV and 7.1 +/- 2.0 mm at the knee, but postoperatively the IDs reverted to those of postoperative patients with a normal deep venous system. To assess patients with recurrences, 366 limbs had simultaneous stripping and contralateral SFJ repair with the Venocuff II. Of these 33 (9%) had recurrences at 4.9 years, 82% of them on the stripping side, and on the repair side half of the recurrences had a competent SFJ (9%). Limbs with an incompetent lateral or anterior accessory system, with an incompetent SFJ (168), were compared with 11 matched randomized controls where stripping was performed. The recurrence rate was 1.2% versus 36% on the strip side. The follow-up for these cases was 6.4 years. Pregnancy (n = 14) produces a high recurrence rate, but stripping and valve repairs were not significantly different, ie, despite small numbers, there was a very strong tendency toward higher recurrence rates on the stripped side. The complication rate was small and the cost of the device is low. The method allows a repairable nonablative approach that can be offered in patients where no other surgical treatment can or should be offered. External stenting to the SFJ is the preferred option for early to moderate varicose veins involving the LSV where the clinical and ultrasonic indicators have been fulfilled.

Efficacy of the Comprehensive Objective Mapping, Precise Image Guided Injection, Anti-Reflux Positioning and Sequential Sclerotherapy (COMPASS) Technique in the Management of Greater Saphenous Varicosities with Saphenofemoral Incompetence

Objective: To evaluate the efficacy of the COMPASS technique in the management of greater saphenous varicosities with saphenofemoral incompetence. Design: Prospective open trial (2-6 year follow-up). Patients: One hundred and eighty-six limbs with refluxing greater saphenous vein (5.4–25.4 mm) and incompetent saphenofemoral junction (6.1–31.3 mm). Main outcome measure: Obliteration, recanalisation, residual veins, neovascularisation, venous dysfunction score. Results: Greater saphenous varicosity is commonly a disease of individuals in their forties, with morbid clinical presentations. Three stages of the COMPASS technique achieved 100% and 98% obliteration of the saphenofemoral junction and greater saphenous vein respectively. There was significant improvement in the venous dysfunction score. Residual refluxing veins were easily managed by sequential treatment. The results are sustained in the 3.4 SD 1.7 year follow up. There was no serious adverse experience reported. Conclusion: The COMPASS technique is safe and highly efficacious in the management of extensive large vein varicose disease.

Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up.

Saphenous vein reflux is often the underlying anatomic cause of varicose veins. It is necessary to eliminate this reflux originating at the saphenofemoral junction (SFJ) to treat the resultant varicose veins. To report 2-year follow-up results after closing the incompetent greater saphenous vein starting from its junction (SFJ) with the femoral vein using radiofrequency (RF) endoluminal ablation. One hundred and forty incompetent greater saphenous veins from 120 patients with an incompetent SFJ and large painful varicosities were treated. Patients were evaluated clinically and with duplex ultrasound at 1 week, 6 weeks, 6 months, 12 months, and 24 months to determine treatment efficacy as well as adverse sequelae. Vein occlusion, defined as the absence of any duplex ultrasound-determined flow, was successfully achieved in 137 of 140 (98%) scanned veins at 1-week follow-up. At the 12-month follow-up, none of the treated patients developed recanalization that was not seen at 6 weeks, with a successful outcome in 90%. At the 24 month follow-up, 19 of 21 patients had complete disappearance of the treated saphenous vein, for a success rate of 90%. Side effects were minimal, and no skin burns or thromboses were observed. RF endovenous occlusion allows patients to obtain treatment with the positive attributes of surgery, that is, a single treatment and low rate of recurrent reflux, but without the morbidity, need for general anesthesia, or extensive convalescence associated with vein stripping and ligation surgery. Patient satisfaction was routinely achieved, with 98% of patients indicating a willingness to recommend the RF endovascular procedure to a friend or family member.

Controlled Radiofrequency Endovenous Occlusion Using a Unique Radiofrequency Catheter Under Duplex Guidance to Eliminate Saphenous Varicose Vein Reflux

BACKGROUND Saphenous vein reflux is often the underlying anatomic cause of varicose veins. It is necessary to eliminate this reflux originating at the saphenofemoral junction (SFJ) to treat the resultant varicose veins. OBJECTIVE To report 2-year follow-up results after closing the incompetent greater saphenous vein starting from its junction (SFJ) with the femoral vein using radiofrequency (RF) endoluminal ablation. METHODS One hundred and forty incompetent greater saphenous veins from 120 patients with an incompetent SFJ and large painful varicosities were treated. Patients were evaluated clinically and with duplex ultrasound at 1 week, 6 weeks, 6 months, 12 months, and 24 months to determine treatment efficacy as well as adverse sequelae. RESULTS Vein occlusion, defined as the absence of any duplex ultrasound-determined flow, was successfully achieved in 137 of 140 (98%) scanned veins at 1-week follow-up. At the 12-month follow-up, none of the treated patients developed recanalization that was not seen at 6 weeks, with a successful outcome in 90%. At the 24 month follow-up, 19 of 21 patients had complete disappearance of the treated saphenous vein, for a success rate of 90%. Side effects were minimal, and no skin burns or thromboses were observed. CONCLUSION RF endovenous occlusion allows patients to obtain treatment with the positive attributes of surgery, that is, a single treatment and low rate of recurrent reflux, but without the morbidity, need for general anesthesia, or extensive convalescence associated with vein stripping and ligation surgery. Patient satisfaction was routinely achieved, with 98% of patients indicating a willingness to recommend the RF endovascular procedure to a friend or family member.

Primary Varicose Veins in the Presence of an Intact Sapheno-Femoral Junction

Objective: To determine the incidence of primary varicose veins (VVs) occurring in the presence of a competent sapheno-femoral junction. Methods: A retrospective analysis of venous duplex scans was performed for all patients referred to the Vascular Unit, The Middlesex Hospital, London, for assessment of primary VVs, over an 18 month period from 1998 to 2000. Results: One thousand nine hundred and eleven patients with primary VVs referred to hospital for treatment were assessed. Their median age was 52 years (interquartile range 39–64 years). The female:male ratio was 1.92:1. Of these, 43.5% had primary VVs in the presence of a competent sapheno-femoral junction (of whom 70.2% were female). Of those patients with primary VVs in the presence of an incompetent sapheno-femoral junction, 62.4% were female. The incidence of primary VVs did not increase overall with age. The peak incidence for women was between 31 and 60 years of age, whilst that for men was between 51 and 70 years. A similar pattern for age distribution was seen irrespective of sapheno-femoral junction status. Men had a reduced incidence of primary VVs in the presence of an intact sapheno-femoral junction compared with incompetent junctions over the age range of 31–60 years. Conclusions: Primary VVs can readily develop in the presence of a competent sapheno-femoral junction. This occurs most frequently in women below the age of 50 years.

Endovenous laser: a new minimally invasive method of treatment for varicose veins--preliminary observations using an 810 nm diode laser.

Long-term success in the treatment of truncal and significant branch leg varicosities, when the saphenofemoral junction (SFJ) and the greater saphenous vein (GSV) are involved, depends on the elimination of the highest point of reflux and the incompetent venous segment, and is best achieved by surgical ligation and stripping. Minimally invasive alternatives in the treatment of varicose veins with SFJ and GSV incompetence have been tried over the years to increase patient comfort, reduce cost and risk, and allow implementation by a wide variety of practitioners resulting in varying degrees of success depending on the fulfillment of the above two premises and the effectiveness of the method used. To demonstrate a novel way to use laser energy through an endoluminal laser fiber for the minimally invasive treatment of truncal varicosities that eliminates the highest point of reflux and the incompetent segment. Patients were treated with 810 nm diode laser energy administered endovenously through a bare-tipped laser fiber (400-750 microm). Vein access for endoluminal placement of the fiber through a catheter was achieved by means of percutaneous or stab wound incision under ultrasound guidance and local anesthesia. Exact placement of the fiber was determined by direct observation of the aiming beam through the skin and by ultrasound confirmation. Preliminary short-term postprocedure results (up to 1 year, 2 months after treatment) in the endovenous laser treatment of 40 greater saphenous veins in 33 patients indicate a 100% rate of closure with no significant complications. In addition, a 2-year experience of 80 cases of isolated branch varicosities (Giacomini, anterolateral branch, etc.) also shows a 100% rate of closure. Early results of our endoluminal laser methodology indicate a very effective and safe way to eliminate SFJ incompetence and close the GSV. With proper patient selection, the ease of methodology and the reduced risk and cost associated with endovenous laser treatment may make it a successful minimally invasive alternative for a wide group of patients that previously would have required ligation and stripping.

Endovenous Laser

BACKGROUND Long-term success in the treatment of truncal and significant branch leg varicosities, when the saphenofemoral junction (SFJ) and the greater saphenous vein (GSV) are involved, depends on the elimination of the highest point of reflux and the incompetent venous segment, and is best achieved by surgical ligation and stripping. Minimally invasive alternatives in the treatment of varicose veins with SFJ and GSV incompetence have been tried over the years to increase patient comfort, reduce cost and risk, and allow implementation by a wide variety of practitioners resulting in varying degrees of success depending on the fulfillment of the above two premises and the effectiveness of the method used. OBJECTIVE To demonstrate a novel way to use laser energy through an endoluminal laser fiber for the minimally invasive treatment of truncal varicosities that eliminates the highest point of reflux and the incompetent segment. METHODS Patients were treated with 810 nm diode laser energy administered endovenously through a bare-tipped laser fiber (400–750 μm). Vein access for endoluminal placement of the fiber through a catheter was achieved by means of percutaneous or stab wound incision under ultrasound guidance and local anesthesia. Exact placement of the fiber was determined by direct observation of the aiming beam through the skin and by ultrasound confirmation. RESULTS Preliminary short-term postprocedure results (up to 1 year, 2 months after treatment) in the endovenous laser treatment of 40 greater saphenous veins in 33 patients indicate a 100% rate of closure with no significant complications. In addition, a 2-year experience of 80 cases of isolated branch varicosities (Giacomini, anterolateral branch, etc.) also shows a 100% rate of closure. CONCLUSION Early results of our endoluminal laser methodology indicate a very effective and safe way to eliminate SFJ incompetence and close the GSV. With proper patient selection, the ease of methodology and the reduced risk and cost associated with endovenous laser treatment may make it a successful minimally invasive alternative for a wide group of patients that previously would have required ligation and stripping.

Transcatheter Duplex Ultrasound-Guided Sclerotherapy for Treatment of Greater Saphenous Vein Reflux: Preliminary Report

Surgical ligation and stripping of the greater saphenous vein has been the gold standard for treatment of saphenofemoral junction incompetence for several years. Although sclerotherapy of the greater saphenous vein has also been advocated by some phlebologists, the procedure can be technically challenging and has resulted in inadvertent nontarget injection. The purpose of this study was to assess the effectiveness and safety of transcatheter duplex-guided sclerotherapy for the treatment of varicose veins due to saphenofemoral junction reflux. Fifty-one greater saphenous veins in 50 patients were treated with transcatheter sclerotherapy. Using local anesthesia and ultrasound guidance, the greater saphenous vein was entered 15-45 cm below the saphenofemoral junction. An infusion catheter was placed over a guidewire and positioned under ultrasound guidance, and 3% sodium tetradecyl sulfate was administered below the saphenofemoral junction and along the course of an "empty" greater saphenous vein via the catheter. Catheter placement and treatment was possible in all patients, with 2-5 ml of 3% sodium tetradecyl sulfate administered per session. At the 24-hour and 1-week follow-ups, all treated greater saphenous vein segments were closed following initial treatment, with no flow detectable by continuous wave or color Doppler interrogation. No patients required re-treatment, with all veins remaining closed at 2- to 12-months follow-up. There have been no adverse reactions. Transcatheter duplex ultrasound-guided sclerotherapy should improve both the safety and efficacy of treatment compared to conventional ultrasound-guided sclerotherapy and offers an alternative to surgical ligation and stripping for those patients wishing to avoid surgery.

Lower extremity superficial venous insufficiency: Percutaneous techniques of management

Tens of millions of people in the United States alone suffer from lower extremity superficial venous insufficiency. In addition to being unsightly, the majority of varicose veins are associated with symptoms which, if left untreated, can lead to venous hypertension and its sequelae. Over the past decade, increased interest in venous disorders and the development of new noninvasive diagnostic tests have contributed to tremendous advancement in the understanding and management of varicose veins. Sclerotherapy has been used effectively for many years, particularly in Europe, and remains the cornerstone of percutaneous treatment of superficial venous insufficiency. Better understanding of the mechanisms of action of sclerosing agents, standardization of treatment methods, and the use of external compression have led to improvements in the technique of sclerotherapy, with superior results and fewer complications. Surgical ligation and stripping of the greater saphenous vein has been the gold standard for treatment of saphenofemoral junction incompetence for several years. Recently, transcatheter duplex-guided sclerotherapy and other new, innovative, minimally invasive techniques have been developed. Early results have shown improved safety and efficacy of transcatheter duplex-guided sclerotherapy compared with conventional ultrasound-guided sclerotherapy for treatment of greater saphenous vein reflux. Although long-term follow-up results are not yet available, these minimally invasive endovenous techniques may offer an excellent alternative to ligation and stripping for those patients who wish to avoid surgery.

Insights in the Development of Primary Venous Reflux

Purpose: The relation between vein wall fibrosis and presence of primary venous reflux was investigated. Methods: Twenty-eight limbs of 27 patients undergoing coronary bypass surgery without history of superficial or deep venous thrombosis and without clinical evidence of varicose veins were subjected preoperative ultrasonic investigation of the long saphenous vein (LSV) and its tributaries in order to detect presence of reflux. Histologic examination of vein specimens, harvested perioperatively from premarked sites of the LSV (ankle, knee, and midthigh) and its tributaries, was carried out. The specimens were classified according to the fibrotic content of the wall on histology as normal, mildly, moderately, and severely affected. Results: Sixteen limbs (57%) had reflux. Saphenofemoral junction (SFJ) incompetence alone was not seen, and this always was present in association with an incompetent LSV (3/16, 19%). Reflux was equally distributed (37.5%) in the above(6/16) and belowknee (6/16) segments, whereas in three limbs it was present throughout the LSV. Fibrosis was seen in the majority of the specimens taken from the LSV (62/65, 95%) and its tributaries (21/32, 66%), irrespective of the presence or absence of reflux. Different grades of fibrosis were found on histology in different sites of the same vein. Conclusions: Venous wall fibrosis very often exists in the absence of reflux and venous insufficiency occurs at any segment of the LSV with minor involvement of the SFJ. Thus, primary venous reflux seems to be a locally developing process.

The use of routine duplex scanning in the assessment of varicose veins.

Clinical assessment has been shown to compare poorly with results of hand-held Doppler examination or venography in the evaluation of varicose veins. Although the use of duplex scanning has been well described in the assessment of varicose veins, there are few data comparing clinical and Doppler assessment with results of duplex scans. A total of 188 patients were referred with varicose veins to a sole specialist vascular surgeon over a 1-year period. After clinical and Doppler assessment, all patients were referred for a duplex scan which was performed by a trained vascular technician. The results of the duplex scan were compared retrospectively with the clinical and Doppler findings. A total of 315 legs were assessed over this period, with 38.7% having recurrent disease and 31.4% having trophic skin changes or ulceration. On duplex scanning, 198 legs (62.9%) had saphenofemoral junction incompetence, 61 legs (19.4%) had saphenopopliteal junction incompetence, 94 legs (29.8%) had perforator incompetence and 24 legs (7.6%) had deep venous incompetence. The respective sensitivity of clinical and Doppler assessment at these sites was 71.2, 36.1, 43.6 and 29.2%. If patients who were felt to have sole saphenofemoral junction incompetence clinically were treated by high ligation, stripping to the knee and stab avulsions, 28.9% would have had sites of reflux untreated. Clinical and Doppler assessment is unreliable. Routine duplex scanning is likely to reduce recurrence by identifying sites of reflux with greater accuracy.

Outpatient Management of Superficial Venous Insufficiency at a Naval Medical Facility

Superficial venous insufficiency is common in a young, working population. It can result in disability and lost time from work because of chronic pain, inflammation, and/or ulceration. We reviewed our experience in the management of 104 patients with superficial venous insufficiency secondary to saphenofemoral and/or perforator venous incompetence. The main treatment objective was to control venous insufficiency in a manner that would allow a rapid return to duty. The technique involved ligation of the incompetent saphenofemoral junction and/or perforating veins (i.e., point ligation) under local anesthesia. Patients returned to normal duty status the day after treatment. Six weeks later any persistent disease was controlled with compression sclerotherapy. Significant morbidity included postoperative wound complications in 4% and thrombophlebitis in 14%. Objectives of treatment, with excellent functional and cosmetic results, were achieved. True recurrence was noted in 8% of patients, whereas new disease developed in only 4%; the total recurrence rate was 12%. This mode of therapy is ideally suited to outpatient management. This study demonstrates the excellent control of venous dysfunction that is achievable with the use of selective therapy based on proximal venous ligation and staged sclerotherapy.

Recurrent varicose veins following high ligation of long saphenous vein: a duplex ultrasound study

Duplex scanning was used to study recurrent varicose veins in 244 limbs with previous high ligation of the long saphenous vein. The recurrent varicose veins were classified into two types according to the presence or absence of a residual long saphenous vein. Varicose veins with a residual long saphenous vein (type I) occurred in 168 limbs (68.9%). A residual long saphenous vein with an incompetent saphenofemoral junction was present in 125 limbs and one without any residual saphenofemoral junction in 43 limbs. Besides the presence of an incompetent long saphenous vein in this group, an incompetent short saphenous vein was detected in 26 limbs, incompetent perforating vein(s) in 45 limbs and incompetent deep veins in 26 limbs. Varicose veins without a residual long saphenous vein (type II) occurred in 76 limbs (31.1%). An incompetent short saphenous vein was demonstrated in 44 limbs, incompetent perforating vein(s) in 18 limbs and incompetent deep veins in 32 limbs. Of the total 244 limbs with recurrent varicose veins, long saphenous vein incompetence was involved in 168 (68.9%), short saphenous vein incompetence in 70 (28.7%), perforating vein incompetence in 63 (25.8%) and deep venous incompetence in 58 (23.8%). Although saphenofemoral junction incompetence was found to be the main source of recurrence, a segment of incompetent residual long saphenous vein, an incompetent short saphenous vein, perforating vein and deep venous system incompetence are other common sources of recurrence. A precise assessment to identify underlying venous incompetence is important for the management of recurrent varicose veins.

Correction of Superficial Incompetence with Selective Saphenous Vein Repair (SSVR)

The aim of this study was to evaluate, in a prospective, five-year follow-up study, selective saphenous vein repair (SSVR) (combined use of plication of the incompetent saphenofemoral junction [SFJ] and selective ligature of incompe tent veins). The effects of SSVR were evaluated by ambulatory venous pressure measurements refilling time (RT) and color duplex to detect the number of incompetent venous sites. From a group of 400 consecutive patients studied for venous incompetence 54 subjects were randomized in an SSVR and a control group. Criteria of inclusion were SFJ incompetence with presence of valve cusps and incompetence of two to five venous sites in the territory of the long saphenous. After five years 22 patients in the SSVR group and 21 in the control group completed the study. SSVR increased RT (p &lt; 0.02), and the number of incom petent sites was decreased after five years (p &lt; 0.02). In the control group RT was shorter and the number of incompetent sites increased (p &lt; 0.05) after five years. In conclusion SSVR appears to be an effective, physiological treatment with good long-term (five-year results) on incompetence and on the prevention of new incompetent sites.