Venous Valvular Incompetence Research Articles

Calf rEF: Impact of Calf Muscle Pump Dysfunction With Reduced Ejection Fraction on All-Cause Mortality

ObjectiveTo evaluate mortality outcomes by varying degrees of reduced calf muscle pump (CMP) ejection fraction (EF). Patients and MethodsConsecutive adult patients who underwent venous air plethysmography testing at the Mayo Clinic Gonda Vascular Laboratory (January 1, 2012, through December 31, 2022) were divided into groups based on CMP EF for the assessment of all-cause mortality. Other venous physiology included measures of valvular incompetence and clinical venous disease (CEAP [clinical presentation, etiology, anatomy, and pathophysiology] score). Mortality rates were calculated using the Kaplan-Meier method. ResultsDuring the study, 5913 patients met the inclusion criteria. During 2.84-year median follow-up, there were 431 deaths. Mortality rates increased with decreasing CMP EF. Compared with EF of 50% or higher, the hazard ratios (95% CIs) for mortality were as follows: EF of 40% to 49%, 1.4 (1.0 to 2.0); EF of 30% to 39%, 1.6 (1.2 to 2.4); EF of 20% to 29%, 1.7 (1.2 to 2.4); EF of 10% to 19%, 2.4 (1.7 to 3.3) (log-rank P≤.001). Although measures of venous valvular incompetence did not independently predict outcomes, venous disease severity assessed by CEAP score was predictive. After adjusting for several clinical covariates, both CMP EF and clinical venous disease severity assessed by CEAP score remained independent predictors of mortality. ConclusionMortality rates are higher in patients with reduced CMP EF and seem to increase with each 10% decrement in CMP EF. The mortality mechanism does not seem to be impacted by venous valvular incompetence and may represent variables intrinsic to muscular physiology.

Residual rates of reflux and obstruction and their correlation to post-thrombotic syndrome in a randomized study on catheter-directed thrombolysis for deep vein thrombosis.

Deep vein thrombosis (DVT) often results in venous valvular incompetence and incomplete recanalization, followed by post-thrombotic syndrome (PTS). Treatment with additional catheter-directed thrombolysis (CDT) in patients with an iliofemoral DVT has been shown to reduce the frequency of PTS. The objective of this study was to assess the effect of CDT on venous reflux and patency and to identify possible predictors for the development of PTS. Open, multicenter, randomized, controlled clinical trial. Patients (18-75years) with a first-time iliofemoral DVT were randomized to receive conventional treatment with anticoagulation and compression stockings or CDT in addition to conventional treatment. Follow-up after 6 and 24months included ultrasound and air plethysmography for evaluation of venous reflux and patency. PTS was assessed with the Villalta score. Possible predictors of PTS were analyzed in multivariate logistic regression models. Following additional CDT, deep venous reflux was detected in 65.2% (95% confidence interval [CI], 54.8-74.2) of patients at 6months and 66.7% (95% CI, 56.4-75.6) at 24months. The absolute risk reduction of deep venous reflux was 11.9% (95% CI, 1.1-24.9) after 6months and 16.5% (95% CI, 4.2-28.8) after 24months in the CDT arm compared with controls. Correspondingly, venous patency was regained in 65.9% (95% CI, 55.5-75.0) of patients at 6months and 74.7% (95% CI, 64.9-82.6) after 24months. Patency was regained in 18.5% (95% CI, 4.4-32.6) more patients after 6months and 15.1% (95% CI, 1.8-28.5) more patients after 24months compared with controls. Independent of treatment allocation, patients with fully recanalized and competent deep veins at 6-month follow-up had a 40.5% (95% CI, 26.4-54.7) absolute risk reduction of developing PTS compared with patients with abnormal vein assessment. Reflux and lack of patency at 6months were found to be independent predictors of PTS development in patients treated with CDT (odds ratio, 8.3; 95% CI, 2.6-26.8 for patients with reflux, and odds ratio, 0.17; 95% CI, 0.06-0.49 for patients with patency). Additional CDT improved patency and reduced reflux. Both parameters were found to be strong predictors of PTS in patients treated with CDT. Noninvasive vein assessments of patency and reflux may be helpful to identify and monitor patients at high risk of PTS. Our findings provide evidence for the importance of early recanalization with CDT for acute iliofemoral DVT.

Association Between Inherited and Acquired Thrombophilias and The Post Thrombotic Syndrome: A Systematic Review and Metaanalysis

Introduction The post thrombotic syndrome (PTS) is a frequent complication of deep vein thrombosis (DVT), occurring in 20-40% of DVT patients. Identifying risk factors for PTS may be useful to provide patients with reliable prognostic information and target prevention strategies. Inherited and acquired thrombophilias are well established risk factors for DVT. We hypothesized that these markers may also increase the risk of PTS. Objective To conduct a systematic review to assess: Among patients with DVT, are inherited or acquired thrombophilias associated with risk of PTS? Methods We conducted a search of the electronic databases PubMed, EMBASE, Scopus, and Web of Science for studies published from 1990-2013. Studies were considered eligible if they reported assessing any thrombophilia in adult DVT patients and its association with the development of PTS. Risk of bias was assessed using a modified Newcastle-Ottawa scale. Meta-analysis was performed by pooling odds ratios (OR) using the random effects model, when three or more studies were available. Results After removal of duplicates, 2376 records were screened and 84 full text articles were assessed for eligibility. Sixteen studies were included in our review: 13 studies assessed Factor V Leiden (FVL), 10 assessed prothrombin gene mutation, 5 studies assessed protein S and C deficiencies, 3 assessed antithrombin deficiency, 4 assessed factor VIII activity, and 6 studies assessed antiphospholipid antibodies (6 studies assessed Lupus Anticoagulant (LAC) and 1 assessed Anticardiolipin Antibody). None of the meta-analyses performed identified any inherited or acquired thrombophilia to be predictive of PTS (Figure 1). We were unable to pool studies reporting the association between Factor VIII and PTS because of clinical heterogeneity, however, descriptively, the predictive value of FVIII for PTS seems to be limited. We conducted subgroup analyses stratifying studies by patient characteristics (Table 1). Both FVL and prothrombin mutations appeared to be protective for PTS among studies including patients with both first and recurrent DVT, and studies where >50% of patients had an unprovoked DVT. Our pooled estimate for the effect of antiphospholipid antibodies is largely based on studies that measured LAC while on anticoagulant treatment, hence may be an underestimate. However, the confidence intervals for the estimates overlapped the null for all of these subgroups. A sensitivity analysis was conducted to restrict to studies that used a more rigorous definition of PTS (using only the Villalta scale). FVL was associated with an OR 0.88 (6 studies; 95% CI: 0.66, 1.18) and prothrombin mutation with an OR 0.91 (6 studies; 95% CI: 0.55, 1.49). Hence, FVL appeared protective when we restricted to higher quality studies. Conclusions Our meta-analysis did not demonstrate a significant association between any of the thrombophilias assessed and the risk of PTS in DVT patients, however, we cannot rule out a mild protective effect of FVL and prothrombin mutation in certain subgroups. As the pathophysiology of PTS involves the complex interplay of persistent venous obstruction, valvular incompetence and inflammation, other biomarkers may be more predictive of the patient’s risk of PTS. Disclosures: No relevant conflicts of interest to declare.

Varicose veins: evaluating modern treatments, with emphasis on powered phlebectomy for branch varicosities

Varicose veins are an early manifestation of chronic venous insufficiency. Although the risk factors associated with varicose veins are well described, the basic pathophysiology leading to venous valvular incompetence, and thus, varicosities are less well known. However, cosmetics aside, the leg fatigue and heaviness that is associated with chronic venous insufficiency in the presence of varicose veins can be disabling. The treatment of superficial vein reflux has evolved in the past 10 years making open surgical ligation and stripping of the great saphenous vein largely a historic procedure. Endovenous ablation using catheter-based techniques achieve vein closure with minimal surgical risk. In the same sense, removal of varicosities associated with superficial reflux has also evolved. Traditionally, varicose veins were removed with multiple stab incisions and hook phlebectomy. The introduction of transilluminated-powered phlebectomy has allowed for removal of large clusters of varicose veins using fewer ...

Perfil clínico e sociodemográfico dos portadores de doença venosa crônica atendidos em centros de saúde de Maceió (AL)

CONTEXTO: A doença venosa crônica (DVC) consiste em alteração do sistema venoso causando uma incompetência valvar associada à obstrução de fluxo ou não. Acomete 10 a 20% da população mundial, tendo maior prevalência no sexo feminino. Apresenta como sintomas mais comuns dor e edema e na forma avançada, a úlcera venosa. Traz limitações funcionais e isolamento social, afetando a qualidade de vida. OBJETIVO: Traçar o perfil dos portadores de DVC, pelo levantamento de dados clínicos e sociodemográficos que indiquem características que possam contribuir para possível mudança de hábito na vida de pacientes que, por motivos de trabalho, falta de conhecimento e/ou instruções, tiveram sua rotina afetada pela doença, com consequente diminuição da sua qualidade de vida. MÉTODOS: Estudo descritivo, observacional do tipo transversal, sendo avaliados portadores de DVC atendidos em centros de saúde de Maceió (AL), aplicando um formulário para coleta de dados, como classificação CEAP, Critério de Classificação Econômica Brasil e Questionário SF-36. RESULTADOS: A amostra foi composta por 66 pacientes com DVC; 83% eram do sexo feminino e 17%, do masculino, a faixa etária predominante foi entre 50 a 60 anos; eram sedentários, assumindo ortostatismo prolongado, baixo nível de escolaridade e classe econômica, doença clínica grave (C6 sintomático) e qualidade de vida variável. CONCLUSÃO: Os resultados demonstraram predomínio da doença no sexo feminino, entre 50 a 60 anos de idade, com fatores desencadeadores e/ou agravantes para desenvolvimento da DVC como falta de atividade física, baixo nível de escolaridade e baixa renda econômica, afetando a qualidade de vida.

The Sixth Pacific Vascular Symposium

Chronic venous disease (CVD) is a common problem worldwide and is primarily related to venous insufficiency of the lower extremity veins. The etiology may be primary, due to venous valvular incompetence; or secondary, due to post deep vein thrombosis (DVT) vein wall damage. The clinical presentation includes leg swelling, pain, lipodermatosclerosis, hyperpigmentation, and venous stasis ulcers (VSUs) (found in the most severe cases). This affects 2.5 million patients per year in the United States and is estimated to cost more than $3 billion per year.1,2 The acute ulcers are problematic and require prolonged medical and surgical care; the recurrence rate of VSUs may be as high as 70%.3 Lack of disease understanding, lack of physician interest, and diffusion of patient care across multiple specialties all contribute to lack of CVD progress. In addition to a thorough medical history and physical examination, standard diagnostic testing for those who present with a VSU should include venous duplex ultrasonography. This yields information about luminal obstruction (post DVT), valvular competence, and whether the insufficiency affects the superficial, deep, or both vein systems anatomically. Similarly, an ideal biomarker would prognosticate patients with mild CVD, either primary or secondary, to either high or low risk of VSU and would be useful for guiding therapeutic interventions. Although several biomarkers, such as intercellular adhesion molecule-1, interleukin 6, and C-reactive protein, have shown some correlation with CVD severity, none are robust enough to use routinely at this point. The Sixth Pacific Vascular Symposium was conducted under the auspices of …

Impact of venous thromboembolism, venous stasis syndrome, venous outflow obstruction and venous valvular incompetence on quality of life and activities of daily living: a nested case-control study.

The role of venous stasis syndrome (VSS) mechanisms (i.e. venous outflow obstruction [VOO] and venous valvular incompetence [VVI]) on quality of life (QoL) and activities of daily living (ADL) is unknown. The objective of this study was to test the hypotheses that venous thromboembolism (VTE),VSS,VOO and VVI are associated with reduced QoL and ADL. This study is a follow-up of an incident VTE case-control study nested within a population-based inception cohort of residents from Olmsted County, MN, USA, between 1966 and 1990. The study comprised 232 Olmsted County residents with a first lifetime VTE and 133 residents without VTE. Methods included a questionnaire and physical examination for VSS; vascular laboratory testing for VOO and VVI; assessment of QoL by SF36 and of ADL by pertinent sections from the Older Americans Resources and Services (OARS) and Arthritis Impact Measurement Scales (AIMS2) questionnaires. Of the 365 study participants, 232 (64%), 161 (44%), 43 (12%) and 136 (37%) had VTE, VSS, VOO and VVI, respectively. Prior VTE was associated with reduced ADL and increased pain, VSS with reduced physical QoL and increased pain, and VOO with reduced physical QoL and ADL.VVI was not associated with QoL or ADL. In conclusion,VSS and VOO are associated with worse physical QoL and increased pain. VOO and VTE are associated with impaired ADL. We hypothesize that rapid clearance of venous outflow obstruction in individuals with acute VTE will improve their QoL and ADL.

Risk factors and underlying mechanisms for venous stasis syndrome: a population-based case–control study

Venous stasis syndrome may complicate deep vein thrombosis (DVT; i.e. post-phlebitic syndrome), but, in most cases, venous stasis syndrome is not post-phlebitic. The objective of this study was to determine the risk factors (including prior DVT) for venous stasis syndrome, and to assess venous outflow obstruction and venous valvular incompetence as possible mechanisms for venous stasis syndrome. This was a case-control study nested within a population-based inception cohort. The study population consisted of 232 Olmsted County, MN residents with a first lifetime venous thromboembolism (VTE) and 133 residents without VTE. Measurements included a questionnaire and physical examination for venous stasis syndrome; strain gauge outflow plethysmography, venous continuous wave Doppler ultrasonography and passive venous drainage and refill testing for venous outflow obstruction and venous valvular incompetence. Altogether, 161 (44%), 43 (12%), and 136 (38%) subjects respectively, had venous stasis syndrome, venous outflow obstruction and venous valvular incompetence. Independent risk factors for venous stasis syndrome included increasing patient age and body mass index (BMI), prior DVT, longer time interval since DVT, and varicose veins. Both venous outflow obstruction (p = 0.003) and venous valvular incompetence (p < 0.0001) were strongly associated with venous stasis syndrome. Increasing age and prior DVT were significantly associated with venous outflow obstruction, while prior DVT, varicose veins and venous stasis syndrome diagnosed prior to the incident DVT were significantly associated with venous valvular incompetence. The risks of venous outflow obstruction, venous valvular incompetence and venous stasis syndrome were higher with left leg DVT. In conclusion, increasing patient age and BMI, prior DVT (particularly left leg DVT), longer time interval since DVT and varicose veins are independent risk factors for venous stasis syndrome. Venous stasis syndrome related to DVT is due to venous outflow obstruction and venous valvular incompetence, while venous stasis syndrome related to older age and to varicose veins is due to venous outflow obstruction and to venous valvular incompetence, respectively.

Effects of primary deep venous valvular incompetence of lower limb in deep vein thrombus after total knee replacement

To evaluate the effects of primary deep venous valvular incompetence of lower limb (PDVI) to the occurrence of deep vein thrombosis (DVT) after human total knee replacement (TKR). One hundred and twenty-six patients who planed to receive TKR were examined by color doppler flow imaging (CDFI). The patients were divided into 2 groups depending on whether they were found backstreaming in femoral vein or not. When the refluxing time > 1 s, the patients were included in PDVI group; When the refluxing time < or = 1 s, the patients were included in without PDVI group. In 7 d after operation all the patients were re-examined by CDFI to find if there was DVT. The results were tested by chi2 statistical analysis. Among the 126 patients, 54 had PDVI, and 72 without PDVI. Fifty patients had DVT, total incidence rate 39.7% (50/126). In PDVI group 33 patients had DVT (61.1%, 33/54); In without PDVI group 17 patients had DVT (23.6%, 17/72), which was lower than PDVI group (chi2 = 21.227, P < 0.05). PDVI may be a risk for occurrence of DVT after TKR.

The PREVAIL Trial and Low-Molecular-Weight Heparin for Prevention of Venous Thromboembolism

Marc Fisher MD Kennedy Lees MD Section Editors: Patients with stroke are at high risk for venous thromboembolism. Studies of the natural history in the era before widespread use of antiplatelet agents or physical preventive measures reported an incidence of deep vein thrombosis (DVT) of over 50% within the first days.1 A lower incidence might be expected with more aggressive routine acute treatment, including early use of antiplatelet agents, early mobilization, and graduated compression stockings, but the combined control groups of randomized, controlled trials (RCTs) predominantly undertaken in the 1990s still reported an incidence of 37% when DVT was specifically sought.2 Older studies found the incidence of pulmonary embolism (PE) after stroke to be 10% to 20% and to account for up to 10% of all fatalities (including cases in ambulant patients).3 In contrast, symptomatic PE is consistently rarely reported in RCTs in stroke, occurring in just 0.7% of randomized subjects in the control group of trials comparing heparins with antiplatelet therapy.4 However, clinical recognition of PE remains poor. Half of all PEs in one series presented as sudden death.5 Clinically unrecognized PE is also common, with up to 50% of surgical patients with proximal DVT having abnormal ventilation–perfusion lung scans.6 Even if PE is rare, postthrombotic syndrome resulting from venous valvular incompetence causes pain, swelling, and skin changes, including varicose eczema, and may affect over 20% of those with symptomatic DVT within 2 years. The effectiveness of low-dose unfractionated heparin for prevention of VTE was established in the late 1970s, predominantly in surgical patients but also in stroke.7 The superiority of low-molecular-weight (LMW) heparins over unfractionated heparin in other clinical settings has also been established with advantages including more predictable dose effects, easier administration, and less risk of thrombocytopenia. Two previous RCTs …

The Perioperative Role of Duplex Venous Scanning in Endovenous Laser Therapy

Varicose veins that emerge as a result of the venous valvular incompetence of the great saphenous vein (GSV) are a common chronic condition affecting millions of people. When invasive treatment is necessary, surgical removal of the GSV and varicosities has been the standard procedure to relieve symptoms. Recent advances in laser technology have resulted in endovenous laser therapy as an alternative to open surgery by ablating the GSV. Duplex venous ultrasound is a critical part of preoperative planning, intraoperative safe execution of the procedure and postoperative care. It is necessary that the vascular surgeon and the sonographer work in tandem and have experience in intraoperative duplex venous scanning to achieve an optimal outcome.

Role of Venous Outflow Obstruction and Venous Valvular Incompetence as Mechanisms for Venous Stasis Syndrome Following Deep Vein Thrombosis: A Population-Based Cohort Study.

Background: Venous stasis syndrome (VSS) is a relatively common long-term sequelae of deep vein thrombosis (DVT), although it frequently is noted in individuals with no prior history of DVT.Objective: To evaluate whether: (1) venous stasis syndrome (VSS) is associated with a prior history of DVT; (2a) venous outflow obstruction (VOO) and/or (2b) venous valvular incompetence (VVI) are associated with DVT; and (3) VSS is associated with VVI and/or VOO.Design: Case-control study nested within a population-based inception cohort study.Population: 230 residents of Olmstead County, MN (OCM) with a first lifetime VTE over the 25-year period, 1966 – 1990 (cases), and 135 age, gender and year of incident VTE-matched OCM residents without prior history of VTE (controls).Measurements: Physical examination and patient questionnaire for symptoms or signs of VSS, and strain gauge outflow plethysmography, continuous wave venous Doppler ultrasound, and passive venous drainage and refill testing for VOO and VVI performed between 1996 – 1998.Results: Of the 365 study participants, 43 (12%) had VOO, 136 (37%) had VVI, and 265 (73%) had VSS. In multivariate logistic regression analyses: (1) age at the follow-up visit [OR Δper 10 years: 1.70 (1.41, 2.04)], prior DVT in the affected limb [OR: 4.03 (2.32, 7.01)], and presence of prior varicose veins [OR: 4.36 (1.84, 10.31)] were significantly associated with VSS; (2a) age at the follow-up visit [OR Δper 10 years (95% CI): 1.84 (1.39, 2.44)] and prior DVT in the affected limb [OR: 5.01 (2.61, 9.63)] were significantly associated with VOO; (2b) prior DVT in the affected limb (OR: 3.91 (2.56, 5.97)], presence of prior varicose veins [OR: 2.19 (1.32, 3.63)] and symptoms of VSS prior to incident DVT [OR: 3.42 (1.46, 8.00)] significantly increased the odds for VVI; and (3) VOO (p=0.004) and VVI (p<0.0001) were highly associated with VSS. Having a DVT in the left leg was associated with a greater odds of developing VOO, VVI or VSS in that leg when compared to their association with right leg DVT (OR: 6.69 vs. 3.65; 4.82 vs. 3.09; 4.71 vs. 3.97, respectively). Interestingly, prior DVT in the opposite leg was associated with an increased odds of subsequent VVI [OR: 2.00 (1.28, 3.10) and VSS [OR: 2.20 (1.31, 3.70)], but not VOO, in the test leg.Conclusions: Prior DVT imparts an increased risk for subsequent VSS, likely due to VOO and/or VVI. The odds of VOO or VSS increases with age. Presence of varicose veins increases the odds for VVI and VSS. We speculate that the increased odds of left sided VOO, VVI and VSS in patients with prior DVT may be secondary to May-Thurner syndrome. The increased odds of VVI and VSS in the limb opposite to the one affected by prior DVT could reflect occult DVT in the test limb, inferior vena cava thrombosis, or other mechanisms leading for VVI and VSS.

Photoplethysmography in the diagnosis of superficial venous valvular incompetence

Photoplethysmography in the diagnosis of superficial venous valvular incompetence

Duplex evaluation of venous insufficiency

Duplex ultrasound is the most useful examination for the evaluation of venous valvular incompetence. Multi-frequency 4 to 7-MHz linear array transducers are typically used for this assessment of superficial and deep reflux. The examination is done with the patient standing and manual compression maneuvers are used to initiate reflux. Automatic rapid inflation and deflation cuffs may be used when a standard stimulus is needed. Cutoff values for reflux have been defined. Perforating veins must be identified and flow direction during compression recorded. When ulcers are present, duplex ultrasound is used to investigate veins of the ulcerated legs. Venous outflow obstruction is also studied by duplex ultrasound and chronic changes in deep and superficial veins following deep venous thrombosis noted. The main drawback in evaluation of chronic obstruction is inability to quantify hemodynamic significance. Anatomic variations in superficial and deep veins are common and their identification is necessary. Reporting results of duplex ultrasound studies must take into consideration the proper classification of venous disease as well as the new anatomic terms that have been accepted.

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.

Early Experience with Radiofrequency Ablation of the Greater Saphenous Vein

Radiofrequency ablation of the greater saphenous vein (GSV) has been proposed as an alternative to conventional ligation and stripping in the treatment of varicose veins. We have reviewed our initial experience with this new technology in 28 procedures on 24 patients. Preoperative duplex scans confirmed venous valvular incompetence of the GSV in all patients. Intraoperative ultrasound was used to measure the depth of the GSV, to precisely place the radiofrequency catheter adjacent to the saphenofemoral junction, and to confirm the results of the ablative procedure. Occlusion of the GSV was seen on 96% of completion scans and in all patients within 1 week of the procedure. Duplex scans were available for 21 limbs at 3 months and for 3 at 1 year. Persistent occlusion was documented in all cases. No patient had paresthesias or thermal skin injury. Two patients had transient superficial thrombophlebitis around the knee in a treated segment of the GSV. One patient was found to have extension of an asymptomatic, nonocclusive thrombus into the common femoral vein on a routine scan 3 days after surgery. Postoperative patient questionnaires showed that 96% of respondents were very satisfied with the procedure. Radiofrequency ablation of the GSV appears to be a safe alternative to conventional stripping and ligation. Subjective assessment by the surgeons suggests an earlier return to work and active lifestyle compared to traditional extirpative techniques. Longer follow-up is required to establish the durability of the procedure.

An open trial of calcium dobesilate in patients with venous ulcers and stasis dermatitis

Venous leg ulcers and associated stasis dermatitis are a major cause of morbidity, economic loss, and decreased quality of life in afflicted patients. Hence, there has been a renewal of interest in the medical management of varicose veins and ulcers. Calcium dobesilate, a capillotropic agent, has been found to be beneficial in the treatment of varicose veins. This is an open pilot study of 25 patients (15 with venous ulcers with/without stasis dermatitis, 10 with stasis dermatitis only) who were given calcium dobesilate, 500 mg twice daily, for 8 weeks. The clinical parameters were graded (0-4; 0, absent; 1, mild; 2, moderate; 3, severe; 4, very severe) both before and after therapy, and included pain, itching, tiredness, heaviness, paresthesia, cramps, and leg swelling. Evaluation also included subjective changes in tenderness, oozing, and pigmentation, and measurement of the circumference of the leg for swelling and malleolar edema (measured in millimeters). The venous ulcer sizes were also recorded both before and after therapy. Color Doppler studies were performed to confirm the diagnosis of varicose veins, determine the competence of the valves, and to rule out deep vein thrombosis. Serum biochemistry, hemogram, and urinalysis were performed both before and after treatment. The results were analyzed statistically using the Wilcoxon rank sum test and Student's t-test. A statistically significant improvement was observed post-therapeutically in the clinical parameters of pain, itching, tiredness, heaviness, and leg swelling. There was also a significant decrease in ulcer size. The serum biochemistry, hemogram, and urinalysis remained unaffected. Color Doppler studies before treatment revealed venous valvular incompetence in 20 patients. They were repeated in only 10 patients after treatment, four of whom showed improved valvular competence. Recurrence of venous ulcers was seen in five of 12 patients who were followed up after therapy. No significant side-effects were noted. Calcium dobesilate is an effective adjuvant therapy, with an absence of significant side-effects, in patients with venous ulcers and stasis dermatitis. More double-blind trials are required in the future to substantiate and evaluate the role of the drug in these two indications.

Oedema in Chronic Venous Insufficiency: Physiopathology and Investigation

Aim: To review the physiology of the venous system in the leg and the events in the microcirculation of the skin leading to development of the symptoms of chronic venous insufficiency (CVI). Method: A review of current literature in the field of CVI has been conducted, with particular reference to the microcirculation and the means of investigating this. Synthesis: Venous valvular incompetence and obstruction in the lower limb causes damage to the microcirculation of the skin. The resulting venous hypertension is resisted by the microcirculation. Cutaneous vasomotion alters, with a prevalence of closing periods of the pre-capillary sphincters, limiting capillary hypertension and resulting in capillary haemoconcentration. This phenomenon promotes drainage of fluids from the interstitial spaces and prevents hypoxic damage to the endothelium. In severe CVI this defence mechanism is overwhelmed, vasomotion declines and arteriolar vasoparalysis occurs. The capillary bed is filled and the intracapillary pressure increases. Reduced microcircula-tory perfusion flow velocity favours capillary plugging by white cells. Leucocyte activation damages the endothelium through the release of proteolytic enzymes, oxygen metabolites and lipid oxidation products. Increased permeability of the endothelium allows passage of fibrinogen and results in a perivascular fibrin cuff. Initially this protects the capillary but later blocks oxygen exchange. These events lead to capillary thrombosis with destruction of capillaries with tissue ischaemia and trophic lesions. Conclusions: The result of venous hypertension in the large veins of the lower limb is damage to the microcirculation of the skin. This leads to lipodermato-sclerosis and eventually ulceration in some patients.

Postthrombotic Syndrome After Hip or Knee Arthroplasty

Although the incidence of the postthrombotic syndrome (PTS) has been addressed in patients with symptomatic deep vein thrombosis (DVT), less information is available on the incidence in patients who develop asymptomatic DVT after major hip or knee arthroplasty. To determine whether symptomatic PTS occurs more frequently in patients who develop DVT after hip or knee arthroplasty than those who are free of DVT and to provide an estimate of the incidence of PTS in patients who had undergone major hip or knee arthroplasty and had proximal DVT, distal (calf) DVT, or no DVT. A cross-sectional study conducted at the Hamilton Health Sciences Corporation, Hamilton, Ontario, and the Academic Medical Centre, Amsterdam, the Netherlands. Two hundred fifty-five subjects who had undergone major hip or knee arthroplasty 2 to 7 years previously and had routine predischarge venography showing proximal DVT (n = 25), distal DVT (n = 66), or no DVT (n = 164) were enrolled from March 1993 through December 1998. The presence of symptomatic PTS confirmed by the presence of objectively confirmed venous valvular incompetence was ascertained. The rates of PTS were low and not significantly different among the 3 subgroups: 1 (4.0%, 95% confidence interval [CI] = 0.1%-20.4%) of 25 patients with proximal DVT, 4 (6.1%, 95% CI = 1.7%-14.8%) of 66 patients with distal DVT, and 7 (4.3%, 95% CI = 1.7%-8.6%) of 164 patients with no DVT. Symptomatic PTS is an uncommon complaint after major hip or knee arthroplasty. Patients who develop postoperative proximal or distal DVT and who receive 6 to 12 weeks of anticoagulant therapy are not predisposed to PTS.

Subfascial endoscopic perforator vein surgery: indications and results.

Subfascial endoscopic perforator surgery (SEPS) is a new, minimally invasive technique performed in patients with advanced chronic venous insufficiency. The objective of the operation is to interrupt incompetent medial calf perforating veins to decrease venous reflux and reduce ambulatory venous hypertension in critical areas above the ankle where venous ulcers most frequently develop. Patients with stasis skin changes and healed or active venous ulcerations are potential candidates for the operation. Preoperative evaluation is performed with duplex scanning of the superficial, deep and perforator system, to diagnose both obstruction and valvular incompetence. Results of the North American SEPS Registry (NASEPS) as well as experience in several individual centers confirmed that the operation has significantly fewer wound complications than the classic open surgical techniques, and that rapid ulcer healing can be achieved. At the Mayo Clinic an ulcer recurrence rate of 12% was observed, with recurrence significantly more frequent in post-thrombotic limbs than in patients with primary venous valvular incompetence. The NASEPS Registry report confirmed a 2-year cumulative ulcer recurrence rate of 28%; ulcer recurrence was significantly more frequent in post-thrombotic limbs, especially in those with deep venous obstruction. SEPS is a new, low-risk, outpatient procedure that effectively decreases perforator reflux in patients with venous ulcerations, and should be added to our armamentarium to treat patients with advanced chronic venous disease. Long-term prospective and randomized studies are, however, still required to provide level I evidence of late efficacy.