Venous Refilling Time Research Articles

Influence of Arterial Disease, Age and Active Ulceration on Venous Refilling Time Measured by Photoplethysmography

This study investigated the influence of arterial disease, patient age and the presence of a venous ulcer on venous refilling time as measured by photoplethysmography. Refilling time was evaluated in 157 control limbs, in 133 limbs with venous disease, in 17 limbs with arterial disease and in 20 limbs with mixed disease (arterial and venous disease) as the cause of ulceration. Refilling time reduced progressively with age in control subjects and was significantly shorter over the age of 50 years. Limbs with venous disease alone had a significantly shorter refilling time when compared with controls (Mann-Whitney U test, P < 0.01); however, there was no alteration in refilling time with age. Limbs with arterial disease, without clinical evidence of venous insufficiency, had a shorter refilling time when compared with controls but a longer refilling time compared with those with venous disease (P < 0.01). The refilling time in patients with mixed ulcers did not differ from those with venous ulcers (P < 0.265). Refilling time measured when an ulcer was present was not significantly different to that measured after the ulcer had healed (P = 0.59). Venous refilling time normally reduces with age but is not affected by arterial disease or the presence of an ulcer. Copyright © 1996 The International Society for Cardiovascular Surgery.

Ambulatory venous pressure: Correlation with skin condition and role in identifying surgically correctible disease

(1) To evaluate the full spectrum of venous skin damage with respect to ambulatory venous pressure. (2) To determine whether the ambulatory venous pressure/tourniquet test can be used to select patients for superficial venous surgery (eg. long or short saphenous stripping). Prospective study. Vascular studies unit. Ambulatory venous pressure was measured in a larger sample of limbs (360) with a wide spectrum of venous disease. In addition the effect of a tourniquet placed below the knee on ambulatory venous pressure and venous refilling time was assessed in 234 limbs. This was compared with Duplex assessment of deep and superficial venous reflux at this site. There was a linear trend towards more severe skin damage with increasing ambulatory venous pressure. Ulceration was associated with more severe calf muscle pump dysfunction (higher ambulatory venous pressure) than were lipodermatosclerosis, eczema or pigmentation. The tourniquet test was not able to distinguish between deep and superficial reflux as determined by Duplex scanning. Ambulatory venous pressure should be used to quantify venous insufficiency and remains the reference standard test of the venous calf muscle pump. The tourniquet test should not be used to select patients for surgery since it cannot distinguish deep from superficial venous incompetence. Venous reflux is best localised using Duplex ultrasound.

Chronic Venous Insufficiency in a Chinese Population: An Anatomic and Functional Study by Continuous-Wave Doppler and Photoplethysmography

A total of 1583 limbs in 878 patients who presented with symptoms of chronic venous insufficiency of the lower limbs were examined in the vascular laboratory. The anatomic distribution of valvular insufficiency was determined by continuous-wave Doppler ultrasound and functional severity was determined by the venous refilling time (VRT) using photoplethysmography. Severity of reflux was assessed using a four-class grading scale (classes 0 to 3) based on clinical and VRT criteria. A mixed incompetence of the valves in the superficial system and the perforators was encountered in the majority of patients (44% in class 0 and 85% in class 3). Deep vein incompetence was less common and usually consisted of isolated proximal incompetence of the common femoral vein (up to 32% in class 3) or was of a mixed type (21% in class 3). Isolated distal deep vein incompetence was uncommon. Proximal femoral vein incompetence and superficial system incompetence at the saphenofemoral junction were associated with severe reflux. There was significant improvement in the VRT in patients with more severe reflux (class 2 or 3) after application of an ankle tourniquet. Symptoms of moderate to severe chronic venous insufficiency and ankle ulceration may be a result of long-standing superficial system incompetence rather than deep venous disease and may thus be amendable to simple saphenofemoral ligation and interruption of perforators.

Comparison of Three Exercises for Evaluation of the Calf Muscle Pump

Objective: To evaluate accurately the calf muscle pump in patients with venous insufficiency using foot vein pressure measurements during three different exercises. Design: Prospective study in three groups, comparing patients with venous disease with controls. Setting: Second Department of Surgery, Tottori University Faculty of Medicine. Patients: Twenty normal legs, 29 legs previously affected by deep vein thrombosis and 36 legs with primary varicose veins. Main outcome measures: The foot vein pressure was measured during ankle dorsiflexions, knee-bending and walking on the spot at 40 paces per minute during which minimum ambulatory venous pressure (AVP) and venous refilling time (VRT) were assessed. Results: The three groups differed significantly from each other in AVP and VRT after dorsiflexion and in AVP during walking on the spot, but not after knee-bending. Conclusion: Dorsiflexion is the most useful exercise distinguishing various severities of venous insufficiency, but walking on the spot is more useful for accurately evaluating the calf muscle pump.

The Utility of Non-invasive Tests for Detection of Previous Proximal-vein Thrombosis

Despite the availability of several diagnostic methods for the detection of deep-vein thrombosis (DVT), the identification of previous episodes of DVT remains a diagnostic challenge. To assess the reliability of a combination of a standardized clinical score with three non-invasive tests: compression ultrasonography (CUS), Doppler ultrasound (DUS), and photoplethysmography (PPG), in determining the presence or the absence of previous proximal DVT. One hundred consecutive unselected outpatients were identified, who had undergone contrast venography six to nine years previously because of the clinical suspicion of DVT (confirmed in 43). They were blindly reinvestigated by a panel of trained operators unaware of venography results. They underwent a clinical evaluation of the lower limb, by applying a standardized score to five symptoms and six signs (grading each item from 0 to 3); a PPG test to determine the venous refilling time; a DUS test to determine the venous reflux separately in the common femoral and the popliteal vein; and a CUS test to determine vein compressibility in the same regions. An abnormal CUS test and/or the demonstration of venous reflux in the popliteal region and/or a high clinical score (> or = 8) identified twenty-four of the 43 (56%) DVT + patients with a specificity of 89%. The combination of normal CUS with the absence of venous reflux in both the common femoral and popliteal vein and a low clinical score excluded previous thrombosis in 45 (79%) of the 57 DVT-patients (negative predictive value, 78%). Abnormal venous reflux in the isolated common femoral vein did not reliably predict the presence or absence of previous DVT. However, this occurred in only 13 (13%) patients. The PPG determination of venous refilling time did not improve the results obtained with the other tests. The combination of a standardized clinical evaluation with the results of CUS and DUS can reliably diagnose or exclude previous proximal-vein thrombosis in almost 90% of patients with previous episodes of suspected DVT.

Valve transplantation to the canine popliteal vein: the utility of a distal arteriovenous fistula and the hemodynamic result of a single functional valve.

The objectives were to transplant a venous valve into the popliteal vein of a canine insufficiency model that would maintain long-term function and then to measure the hemodynamic benefit of such a valve. Indexes of venous valvular function, including venous filling time, 90% of venous refilling time, and simulated ambulatory venous pressure, were measured in 11 greyhounds before intervention (Control) and after hind limb venous valvulotomy, which produces chronic venous insufficiency. Three weeks later a valve-containing segment of external jugular vein was transplanted to the popliteal vein with (n = 6) or without (n = 5) a distal arteriovenous fistula. The fistula was ligated in 4 to 6 weeks. Repeat venous indexes were obtained an average of 2 weeks after the last operative intervention. Gross anatomic inspection +/- duplex scanning performed before the animals were killed were used to distinguished normal from damaged valves. Four of five simple valve transplants demonstrated scarring and/or thrombosis and the average venous filling time, ambulatory venous pressure, and 90% of venous refilling time were consistent with chronic venous insufficiency and/or obstruction. One fistula failed in the six valve distal arteriovenous fistula transplants, and that valve was incompetent. Analysis of the remaining five functional valves demonstrated venous filling time consistent with chronic venous insufficiency, normalization of ambulatory venous pressure, and 90% of venous refilling time between normal, and chronic venous insufficiency. These valves appeared normal. Popliteal vein valve transplant anatomy is preserved by an adjunctive distal arteriovenous fistula, and a competent valve transplant improves postexercise venous hemodynamics to approach those of a normal limb.

Digital Photoplethysmography and Light Reflection Rheography

Light reflection rheography (LRR) is appropriate for the global assessment of calf-pump insufficiency regardless of whether it is caused by varicosity, the post-phlebitic syndrome, or deep venous thrombosis. The instrument has been increasingly used by many phlebologists. Digital photoplethysmography (D-PPG) is a further development of this well-established LRR. With this D-PPG instrument it is possible, in contrast to LRR, to calibrate the reflected light. To compare the venous refilling times of both the LRR and the D-PPG when measured at the same time on the same leg. We also evaluated the practical use of both instruments. In total we performed 152 simultaneous measurements with both instruments. We found a statistically significant correlation when we compared the venous refilling time of both LRR and D-PPG (r = .664; P < .001). The observed agreement between both instruments for detecting a disturbed venous refilling time (< or = 25 seconds) is 92%. Both instruments seems to correlate as has been shown in this and other studies. The D-PPG has the advantage of being more handy. Furthermore the reflected light is calibrated, which enables to compare intra- and interindividual measurements.

Double-Blind Trial of the Efficacy of Troxerutin in Chronic Venous Insufficiency

Objective: To evaluate the efficacy of troxerutin in chronic venous insufficiency. Design: Randomized, double-blind, multicentre, prospective controlled trial. Setting: Hôtel Dieu Hospital and Notre Dame de Bon Secours Hospital, Paris, France. Patients: Sixty-nine patients with truncal varicose veins. Intervention: After a single-blind 15-day placebo run-in period, one group ( n = 34) received troxerutin 3500 mg daily for 2 months. The other group ( n = 35) received a placebo. Main outcome measures: Subjective symptoms, ankle circumference, venous refilling time with photoplethysmography, erythrocyte aggregation using the SEFAM aggregameter and fibrinogen level. Results: Leg aching ( p &lt; 0.001) and venous function score ( p &lt; 0.001) improvements were significantly higher in the troxerutin group (83% and −3.7) compared with the placebo group (23% and −0.7). A significant difference in favour of troxerutin was found for erythrocyte aggregation kinetic indexes ( p &lt; 0.001) and dissociation threshold ( p &lt; 0.01). Conclusions: This study confirmed the dual action of the drug: a parietal effect and a rheological effect.

Free flap valvular transplantation for refractory venous ulceration

Nonoperative therapeutic approaches to chronic venous ulceration, although effective, often require prolonged dressing care and immobilization with leg elevation. Results of skin grafting, perforator ligation, and valve interpositions and reconstructions improve results of ulcer healing but have not uniformly prevented ulcer recurrence. Our hypothesis is that reconstruction of chronic venous ulcers by excision of the diseased tissue bed and replacement with a free flap containing multiple competent microvenous valves and a normal tissue microcirculation will result in long-term cure of these debilitated patients. Six patients with chronic venous insufficiency and recurrent ulceration (class 3) underwent excision of ulcers and surrounding liposclerotic tissue beds and reconstruction with fasciocutaneous free flaps (two bilateral). Preoperative and postoperative photoplethysmography was used to assess venous refilling times. Duplex scanning was performed to assess deep venous reflux. There were no flap failures. Photoplethysmographic venous refilling times measured on flaps demonstrated significant immediate and long-term increases from preoperative values (all results +3 by Society of Vascular Surgery outcome grading). Long-term maintenance of tissue integrity is shown by absence of recurrent ulceration and no evidence of recurrent tissue lipodermatosclerosis in all flaps at follow-up (8 months to 7.5 years; mean 24 months). No recurrent lipodermatosclerosis was seen on flap biopsy at 2 and 7 years. Separate cadaveric injection studies, including scanning electron microscopy, revealed numerous microvenous valves directed toward the draining pedicle in the flaps used for reconstruction. This is the first comprehensive report providing combined laboratory and clinical evaluation, anatomic rationale, and long-term outcome of surgical rehabilitation of patients with chronic venous ulceration who have undergone microsurgical flap reconstruction.

Venous valve repair: Early results in fifty-two cases

Chronic deep venous insufficiency, usually secondary to the postthrombotic syndrome, is due to primary valve failure in approximately 15% of cases. In these cases surgical repair of the valvular mechanism may be indicated. Fifty-two limbs in 42 patients were treated with superficial femoral vein valvuloplasty after appropriate investigation. Adjunctive operations on the superficial or perforating veins were performed on 49 limbs during the same hospital admission. Of the 27 patients who have completed one year of follow-up, 85% are free of reflux on duplex scanning and 68% have had normalization of venous refilling times. Of 11 limbs with venous ulceration followed up for more than 1 year, only one has had a recurrent ulcer (9%). In patients without ulceration the procedure has been successful in alleviating symptoms of venous insufficiency. We conclude that the procedure, in conjunction with appropriate superficial venous operation, is effective in selected patients with deep vein reflux whose conditions remain uncontrolled by conservative measures. At 1 year, 85% of valvuloplasties in this series remained competent.

Variability of venous-hemodynamics with daily activity.

This study was designed to evaluate changes in venous hemodynamics that occur in normal, symptom-free male and female volunteers, as a consequence of daily activity. Each leg of 25 symptom-free volunteers was prospectively studied twice in the early morning and twice in the late afternoon on 2 days. Air plethysmography was used to evaluate venous volumes, venous valvular function, calf muscle pump function, and the noninvasive equivalent of ambulatory venous pressure. There was significant change in venous valvular function (venous filling index) indicating progressive insufficiency in the late afternoon compared with the results of the morning studies (p = 0.039). This was demonstrated by a shortened venous filling time (p = 0.033) but not a change in venous volume (p = 0.794). Calf muscle pump function and ambulatory venous pressures remained constant. Although there were significant leg volume and ejection volume differences at baseline in male volunteers compared with female volunteers, no gender differences were evident as a result of daily activity. Five of 25 (20%) volunteers and seven of 50 (14%) extremities had normal venous refill times and venous function index in the morning, which became abnormal in the afternoon, indicating deterioration of venous valve function. Venous hemodynamic changes occur normally as a consequence of daily activity and seem to result from valvular dysfunction. This occurs in men and women and can alter diagnostic conclusions in 20% of otherwise normal patients. These findings have important implications for venous testing and accurate patient evaluation. However, extrapolation of these data to patients with established venous disease should not be made.

Compliance Changes in Venous Insufficiency

In 37 patients (69 limbs) referred to Mayo Clinic's Vascular Center for possible venous valvular insufficiency in the lower limb, calf muscle pump function, calf compliance, and venous refilling times were measured by strain gauge plethysmography techniques. Patient limbs were separated into four categories based on 90% refilling time (T90) following fifteen deep knee bends: normal (n = 16), mild/moderate (n = 28), severe (n = 16), and edema of nonvenous origin (n = 9). Pump function was assessed in actual pumping volumes (mL) and in percent pumping volumes (mL/100 mL), and was reduced in all noncontrol categories. Calf compliance was assessed in actual volume change (mL/mmHg) and in percent volume change (mL/100 mL/mmHg) and was increased in the severe reflux category. Ten study patients had 1 normal category limb and 1 reflux category limb. Paired analysis of these limbs showed pump function to be decreased and calf compliance to be increased in the diseased group limbs.

Duplex Scanning and Light Reflection Rheography in the Assessment of the Severity of Short Saphenous Vein Incompetence

Duplex ultrasound assessment of veins in the popliteal fossa is an accepted alternative to venography. Light reflection rheography provides additional quantitative information on venous reflux in chronic venous insufficiency. To use duplex ultrasound and light reflection rheography to study the venous reflux patterns in the popliteal fossa in a group of patients. Duplex ultrasound examination and light reflection rheography were used in the assessment of the severity of short saphenous vein incompetence. The study revealed that any associated deep venous reflux which was detectable beyond the saphenopopliteal junction represented a more advanced stage of superficial venous insufficiency. Light reflection rheography, as a semiquantitative test, provided useful additional information to duplex scan findings in assessing venous reflux of the popliteal fossa. Short saphenous vein reflux with functional deep venous incompetence was associated with shorter venous refilling times and clinically represented a more advanced stage of primary varicose vein disease.

A rational approach to detection of significant reflux with duplex Doppler scanning and air plethysmography

Purpose: Several techniques are currently available for the detection of venous reflux. We have attempted to determine the relative value and accuracy of available techniques to develop a logical strategy of investigation in reflux venous insufficiency.Methods: The morphologic distribution of venous incompetence (erect duplex and descending venography); the results of ambulatory venous pressure measurement, venous refilling time, the Valsalva test, and air-plethysmography (venous refilling index, VFI); and the clinical severity were described in 118 consecutive limbs. In an attempt to validate the tests, results were correlated with the clinical severity classification (class 0, n = 34; class 1, n = 42; class 2, n = 11; class 3, n = 31) and with a standardized quantification of reflux (multisegment score) as seen on standing duplex Doppler scanning with rapid deflation cuffs.Results: Twenty-nine percent of limbs with severe venous disease (class 23) had pure deep insufficiency, only 6% had pure superficial disease, and the remainder had a combination. A history of previous thrombosis and the presence of posterior tibial vein incompetence were markedly common with ulcer disease (84% and 42%, respectively). The duplex Doppler multisegment score correlated strongly with clinical severity classification (r = 0.97). The venous refilling time and VFI had the highest sensitivity in identifying severe venous disease (class 23), and the ambulatory venous pressure had excellent specificity.Conclusions: For noninvasive determination of reflux, the combination of VFI and duplex scanning not only localized the reflux but also separated severe clinical vein disease from mild, with high sensitivity and specificity. Air plethysmography may also provide valuable information regarding calf muscle pump and outflow obstruction.

Hydrotherapy for Varicose Veins: A Randomized, Controlled Trial

Objective: To assess the effectiveness of regular hydrotherapy in primary varicose veins. Design: Randomized, single blind, prospective, controlled trial. Setting: Social security system related rehabilitation center for employees (nationwide assignment of inpatients). Patients: 122 patients with primary varicose veins. Interventions: Group A (n=60) received daily treatments during 24 days that consisted of external application of alternating cold and warm water to both lower extremities. Group B (n=62) served as controls and was not treated with hydrotherapy. Both groups were comparable in terms of concomitant diseases and treatments. Main outcome measures: Foot volume, ankle circumference and venous re-fill time, using light reflex rheo-graphy, served as objective variables, while a number of typical symptoms were recorded as subjective parameters. Results: A more pronounced improvement in all objective signs in group A compared to B was observed. Four out of seven subjective symptoms improved more frequently in group A than in B. Conclusions: Hydrotherapy is effective in treating primary varicose veins. It can be considered as an adjunct measure to compression therapy and other conservative treatments.

Popliteal Valvular Construction Using a Silastic Sling (Technique II) for Deep Venous Insufficiency of the Lower Limb

Objective: To establish the safety and efficacy of a silastic sling procedure for reconstructing popliteal vein. Design: Prospective survey of patients undergoing surgical treatment for popliteal vein reflux. Setting: Department of Surgery, County Hospital, Bad Karlshafen, Germany. Patients: 209 patients undergoing surgery for popliteal vein incompetence. Interventions: Silastic sling procedure (Technique II) for correction of popliteal vein incompetence. Main outcome measures: Continuous wave Doppler ultrasound examination of popliteal vein, ambulatory foot vein pressure measurements, lower limb venography. Results: One week following surgery 202 patients (of 209) reported relief of pain and reduction of limb oedema. 77 patients with ulcers (of 85) healed following the surgical procedure. Ambulatory venous pressure improved from 71 SD 11 mmHg to 36 SD 17 mmHg. There was prolongation of the venous refilling time from 9 SD 5 seconds to 27 SD 17 seconds. Postoperative phlebography in 92 patients was performed on the tenth post-operative day and in no patient was deep vein thrombosis observed. In 82 of these patients phlebography demonstrated that the constructed popliteal valve was patent. Conclusions: Construction of a popliteal valve using the author's silastic sling technique is a satisfactory method for managing patients with otherwise uncontrolled popliteal vein reflux due to either primary valvular failure or previous deep vein thrombosis.

Femoral vein valvuloplasty: Intraoperative angioscopic evaluation and hemodynamic improvement

Femoral vein valvuloplasty (FVV) is the operation of choice for primary valvular incompetence, but this procedure is highly operator dependent for judging the competence of the valve repair during surgery. We have reviewed our experience with FVV, focusing on the utility of angioscopic-guided valve repair and hemodynamic results. Nine limbs in six patients underwent superficial FVV. There were four men and two women; the average age was 49 years (range 32 to 62 years). All limbs were Society for Vascular Surgery/International Society for Cardiovascular Surgery clinical stage III (venous ulcer), and descending phlebography showed grade 4 reflux in six limbs, grade 3 reflux in one limb, and grade 2 reflux in two limbs. In addition to FVV, five limbs underwent subfascial ligation of incompetent perforators and three limbs underwent ligation and stripping of superficial varicosities. Two limbs underwent polytetrafluoroethylene wrapping of the valvuloplasty. The last five valvuloplasties underwent angioscopic evaluation of the repair, and the last two procedures were closed valvuloplasties (without venotomy). Follow-up averaged 20.3 months (range 2 to 51 months). In all patients ulcers healed without recurrence. There were two perioperative deep vein thromboses in the polytetrafluoroethylene wrapped repairs. All superficial femoral veins were patent by duplex scanning at the time of follow-up. Venous refill time measured by light reflection rheography did not improve after surgery. Venous filling index measured by air plethysmography showed near normalization (3.83 ± 0.82) after angioscopically guided FVV. Duplex quantification of venous reflux was normalized in the group evaluated angioscopically, with a superficial femoral vein reflux time of 0.64 ± 0.44 second and popliteal vein reflux time of 0.68 ± 0.53 second. Angioscopically guided femoral vein valvuloplasty can achieve clinical and hemodynamic results equal to or better than standard open FVV.

Long-term results of venous reconstruction after vascular trauma in civilian practice

The natural history of venous reconstruction (VR) in terms of patency and clinical outcome after vascular trauma has not been well documented. This study consists of 32 patients who had VR performed for extremity vascular trauma and were available for long-term assessment (mean follow-up time 49 months, range 6 to 108 months). The types of repair performed were as follows: lateral venorrhaphy (simple repair) (56%), interposition grafting (22%), patch repair (12.5%), and end-to-end repair (9.5%). Seventeen patients underwent venography after the operation with documentation of repair patency in eight patients (46%) and thrombosis in nine (54%). Only two patients had significant clinical edema at follow-up examination. Noninvasive venous evaluation consisted of Doppler ultrasonography, impedance plethysmography, photoplethysmography, and color-flow duplex scanning (CFDS). The photoplethysmography-derived venous refilling time of the injured extremity was 34.9 ± 16.2 seconds, whereas that of the contralateral noninjured extremity was 36.8 ± 16.1 seconds (p = 0.5). Based on standard criteria for CFDS, 90% of VRs were patent. Eight repairs that were patent in the early postoperative period remained patent on CFDS. Of the nine repairs with early thrombosis, eight were assessed as patent on follow-up CFDS. In conclusion, VR is a durable surgical procedure associated with minimal morbidity, good long-term patency, and preservation of venous competence. The natural history of thrombosed VRs appears to be one of thrombus absorption with recanalization.

Clinical, hemodynamic, and anatomic predictors of long-term outcome of lower extremity venovenous bypasses

Forty-three patients, 24 with crossover femoral saphenous vein bypasses and 19 with saphenopopliteal vein bypasses, were observed for a mean of 5.5 years. All underwent preoperative and sequential postoperative clinical, hemodynamic and foot venous pressure measurement, and anatomic evaluations (duplex and venography). Seventy-one percent of patients undergoing crossover femoral saphenous vein bypasses and 74% of patients undergoing saphenopopliteal vein bypasses had an abnormal preoperative maximum venous outflow, in contrast to 4% and 11% after operation ( p = 0.0183). The mean immediate postoperative maximum venous outflow improvement for patients having crossover femoral saphenous vein bypasses and those having saphenopopliteal vein bypasses was 16 and 17 ml, respectively, and the mean late improvement was 19 and 27 ml, respectively. Ninety percent of the patients undergoing crossover femoral vein bypasses and those having saphenopopliteal vein bypasses had abnormal foot venous pressures in contrast to 18% and 22% after operation. The final clinical outcomes (over 1 year) for both patients having the crossover saphenous vein bypasses and those having saphenopopliteal vein bypasses, respectively, were significant improvement (+3 and +2), 63% and 58%; significant worsening (−2), 4% and 5%. Eighty-eight percent of patients undergoing crossover femoral saphenous vein bypasses and 79% of patients undergoing saphenopopliteal vein bypasses with abnormal preoperative maximum venous outflow measurements had significant clinical improvement. In contrast, 86% of patients undergoing crossover femoral saphenous vein bypasses and 80% of patients undergoing saphenopopliteal vein bypasses with normal preoperative maximum venous outflow had no improvement. Seventy-seven percent of patients having saphenopopliteal vein bypasses and a normal venous refill time had significant improvement, in contrast to 17% for patients with an abnormal venous refill time (<10 sec). Sixty-seven percent of patients undergoing crossover femoral saphenous vein bypasses and 78% of patients undergoing saphenopopliteal vein bypasses with abnormal foot venous pressure measurements had significant improvement. The cumulative 7-year patency was 75% for patients having crossover femoral saphenous vein bypasses and 56% for those having saphenopopliteal vein bypasses. The operative mortality rate was 0% for both procedures, and the complication rate was 4% and 10%, respectively. The most important preoperative variables that correlated with a good outcome were a low preoperative maximum venous outflow, venous refill time >10 sec, and venous claudication and iliac vein compression. Patients with a normal maximum venous outflow measurement and severe venous reflux should not be candidates for these bypasses.

Clinical, hemodynamic, and anatomic predictors of long-term outcome of lower extremity venovenous bypasses

Forty-three patients, 24 with crossover femoral saphenous vein bypasses and 19 with saphenopopliteal vein bypasses, were observed for a mean of 5.5 years. All underwent preoperative and sequential postoperative clinical, hemodynamic and foot venous pressure measurement, and anatomic evaluations (duplex and venography). Seventy-one percent of patients undergoing crossover femoral saphenous vein bypasses and 74% of patients undergoing saphenopopliteal vein bypasses had an abnormal preoperative maximum venous outflow, in contrast to 4% and 11% after operation (p = 0.0183). The mean immediate postoperative maximum venous outflow improvement for patients having crossover femoral saphenous vein bypasses and those having saphenopopliteal vein bypasses was 16 and 17 ml, respectively, and the mean late improvement was 19 and 27 ml, respectively. Ninety percent of the patients undergoing crossover femoral vein bypasses and those having saphenopopliteal vein bypasses had abnormal foot venous pressures in contrast to 18% and 22% after operation. The final clinical outcomes (over 1 year) for both patients having the crossover saphenous vein bypasses and those having saphenopopliteal vein bypasses, respectively, were significant improvement (+3 and +2), 63% and 58%; significant worsening (-2), 4% and 5%. Eighty-eight percent of patients undergoing crossover femoral saphenous vein bypasses and 79% of patients undergoing saphenopopliteal vein bypasses with abnormal preoperative maximum venous outflow measurements had significant clinical improvement. In contrast, 86% of patients undergoing crossover femoral saphenous vein bypasses and 80% of patients undergoing saphenopopliteal vein bypasses with normal preoperative maximum venous outflow had no improvement. Seventy-seven percent of patients having saphenopopliteal vein bypasses and a normal venous refill time had significant improvement, in contrast to 17% for patients with an abnormal venous refill time (less than 10 sec). Sixty-seven percent of patients undergoing crossover femoral saphenous vein bypasses and 78% of patients undergoing saphenopopliteal vein bypasses with abnormal foot venous pressure measurements had significant improvement. The cumulative 7-year patency was 75% for patients having crossover femoral saphenous vein bypasses and 56% for those having saphenopopliteal vein bypasses. The operative mortality rate was 0% for both procedures, and the complication rate was 4% and 10%, respectively. The most important preoperative variables that correlated with a good outcome were a low preoperative maximum venous outflow, venous refill time greater than 10 sec, and venous claudication and iliac vein compression. Patients with a normal maximum venous outflow measurement and severe venous reflux should not be candidates for these bypasses.