Venous Valvular Reflux Research Articles

Radiofrequency ablation for markedly incompetent perforators versus compression therapy in the management of post-phelebtic venous ulcers: A randomized controlled trial.

Venus ulcers developed mainly due to reflux of incompetent venous valves in perforating veins. In this randomized controlled trial, 119 patients recruited over two years, with post-phelebtic venous leg ulcers, were randomly assigned into one of two groups: either to receive radiofrequency ablation of markedly incompetent perforators (Group A, n = 62 patients) or to receive conventional compression therapy (Group B, n = 57 patients). Follow-up duration required for ulcer healing continued for 24 months post randomization. Statistically significant shorter time to healing (ulcer complete healing or satisfactory clinical improvement) between both groups (56 patients, 90.3% of cases in Group A versus 44 patients 77.2% of cases in Group B) over the follow-up period of 24 months was attained (p = 0.001). Also, significantly different ulcer recurrence was recorded between both groups, 8 patients (12.9%) in Group A versus 19 patients (33.3%) in Group B (p = 0.004). In absence of deep venous obstruction, the monopolar radiofrequency ablation for incompetent perforators is a feasible and effective method that surpasses the traditional compression protocol for incompetent perforator-induced venous ulcers in terms of time required for healing even in the presence of unresolved deep venous valvular reflux.

Retrograde administration of ultrasound-guided endovenous microfoam chemical ablation for the treatment of superficial venous insufficiency

ObjectiveThis study measured patient outcomes among symptomatic patients with superficial chronic venous insufficiency who were treated with retrograde ultrasound-guided polidocanol microfoam 1% in a community setting. MethodsBetween March 2015 and June 2017, 250 symptomatic patients with C2-C6 chronic venous insufficiency received polidocanol microfoam 1% and were followed for 16 ± 7 months. Sixteen of the 250 patients (6.4%) had skin ulcers, and 56 (22.4%) were treated previously with thermal or surgical interventions. All patients underwent a duplex ultrasound venous incompetence study to map perforators and veins to be treated. Incompetent veins were accessed with a micropuncture needle distal to the midthigh perforator, approximately 10 cm above the knee fold. The leg was then elevated 45°. Under ultrasound guidance, the incompetent greater saphenous vein was closed with polidocanol microfoam 1%. A second injection was administered through the same catheter directing the microfoam to flow in a retrograde fashion through the incompetent venous valves to the ankle. ResultsAll patients completed the initial treatment; 55 (22.0%) required planned secondary treatment during the follow-up period for residual venous reflux in the below-knee greater saphenous vein. Complete elimination of venous valvular reflux and symptom improvement was documented in 236 patients (94.4%). Minor adverse events included asymptomatic deep vein thrombi (n = 2), common femoral vein thrombus extension (n = 1), and superficial venous thrombi (n = 4). Of the 16 patients with skin ulcers, 10 were C6 patients and 80% experienced wound closure within 4 weeks of treatment. ConclusionsRetrograde administration of polidocanol microfoam 1% is a safe and effective treatment with important clinical benefit for superficial venous insufficiency in community practice.

Alcohol Consumption, High-Density Lipoprotein Cholesterol, Antithrombin III, and Body Mass Index Are Associated with Great Saphenous Vein Reflux in the Thigh

Venous valvular reflux is the main cause of chronic venous dysfunction. However, the etiology of valvular reflux is not completely understood. We conducted this study to investigate new risk factors for venous reflux of the great saphenous vein (GSV) in the thigh. We studied 139 consecutive patients (278 legs) who underwent Doppler ultrasonography at our hospital between March 2015 and February 2016 for leg discomfort with visible varicosities, edema, skin changes, or venous ulcer in the legs. Continuous variables included age, body mass index (BMI), hematological and blood chemistry parameters, smoking (pack-years), and alcohol consumption (days). Nominal variables included sex, comorbidities, smoking status, alcohol drinking status, and specific antibodies. The relationship of GSV reflux with pregnancy and number of children was investigated in 184 legs of 92 patients among 96 female patients. On logistic regression analysis, independent factors determining GSV reflux were BMI (B=0.126, P=0.012), high-density lipoprotein (HDL) cholesterol level (B=0.029, P=0.025), duration of alcohol consumption (B=1.237E-4, P=0.016), and antithrombin III level (B=-0.036, P=0.011). In this study, the factors determining GSV reflux were higher HDL cholesterol level, longer duration of alcohol consumption, lower antithrombin III level, and higher BMI.

Primary venous insufficiency increases risk of deep vein thrombosis.

Varicose veins have been recognized as a risk factor for deep vein thrombosis (DVT). However, venous reflux has not carried the same correlation. This study evaluated the association between primary valvular reflux and DVT. We performed a nested case-control study with enrollment of outpatients presenting to the vascular laboratory with signs and symptoms of DVT. All patients had a complete bilateral venous duplex examination evaluating for DVT and superficial and deep venous valvular reflux. Eighty-seven patients with confirmed DVT on venous duplex were selected for the study group. The control group was randomly selected from the same cohort in a 4:1 ratio matched by age and gender (n = 348). Groups were compared for the prevalence of deep and superficial reflux. DVT outpatients were 4.7-times more likely to have primary valvular reflux than symptomatic controls (65.5% vs 29.0%; 95% confidence interval [CI], 2.8-7.7; P < .000001). Deep reflux was 2.1-times more prevalent (36.8% vs 21.6%; odds ratio, 2.12; 95% CI, 1.28-3.51; P = .005) and superficial reflux was 4.6-times more prevalent (43.7% vs 14.4%; odds ratio, 4.62; 95% CI, 2.75-7.77; P < .0000001) in DVT patients than in controls. DVT patients were also 2.1-times more likely to have combined deep and superficial reflux than non-DVT patients (13.8% vs 6.6%, 95% CI, 1.08-4.75; P = .044). The prevalence of primary valvular reflux in patients with DVT is significantly higher than expected. Reflux may be considered as a novel risk factor for DVT. Two-thirds of patients with DVT have pre-existent primary chronic venous disease, which is likely to contribute to post-thrombotic morbidity.

Management of Venous Ulcers

Chronic venous insufficiency (CVI) results from venous hypertension secondary to superficial or deep venous valvular reflux, as well as venous obstruction. The most severe clinical manifestation of CVI is venous leg ulceration that can result in significant morbidity, including venous gangrene and amputation, albeit rare. Treatment modalities are aimed at reducing venous hypertension. Diuretic therapy, although widely used, only provides short-term improvement of the edema but provides no long-term benefit. Compression therapy is the cornerstone in the management of CVI. Compression can be achieved using compression bandaging, compression pumps, or graduated compression stockings. Topical steroid creams may reduce inflammation, venous eczema, and pain in the short term, but they can be detrimental in the long run. Apligraf (a living, bilayered, cell-based product) in conjunction with compression therapy was noted to be more effective in healing venous leg ulcerations, when compared with treatment with compression therapy and zinc paste. Endovascular and surgical techniques that minimize valvular reflux and relieve venous obstruction improve venous hemodynamics, promoting wound healing.

Systematic Review of the Surgical Treatment of Moderate to Severe Post-Thrombotic Syndrome

AbstractAbstract 3170 Background:Post-thrombotic syndrome (PTS) occurs frequently following deep venous thrombosis (DVT) and is severe in 5–10% of patients. PTS is a burdensome and costly condition due to its chronicity. Management of PTS has included the use of medical therapy such as compression, and less frequently, surgical therapies. Objective:To summarize surgical approaches to the treatment of PTS reported in the literature and to systematically review their effectiveness and safety. Method:A computerized search was conducted using PubMed and reverse citation searches to retrieve articles reporting on the surgical treatment of PTS. We limited our search to English and French language articles published after 1980. Only articles that presented results of outcomes after a surgical technique performed in patients with confirmed PTS were considered. Results:A total of 302 titles were retrieved, of which 27 full publications were reviewed. Eleven articles (8 prospective and 3 retrospective cohort studies) were identified that met criteria for inclusion in our review. Five were single center and six were two-center studies, and none included control patients who did not undergo surgery. The studies reported on a total of 315 patients with moderate to severe PTS who had failed medical therapy. Surgical techniques included percutaneous interventions such as vein dilation and stent placement (1 study), venous bypass grafting (2 studies), endophlebectomy with reconstruction (1 study), valve reconstruction/transplant (6 studies) and interruption of perforating veins (1 study). Follow-up period after surgery ranged from 10 months-5 years.Effectiveness outcomes measured in the studies varied widely. Anatomical outcomes included rates of venous valve competency and patency, venous filling times and ambulant venous pressure as determined by venography or Doppler ultrasound. Clinical outcomes assessed included improvement in signs and symptoms (e.g. pain, swelling, hyperpigmentation), ulcer healing, ability to return to work and reduced need for elastic compression stockings. Three studies used a quantitative scoring system to report clinical outcomes while 8 studies reported qualitative change only. Safety outcomes reported included surgical site bleeding, vessel injury, hematoma/seroma formation, infection, DVT, cellulitis, lymphocele, dysesthesia and acute valve rejection.Ten of 11 studies included for review described some improvement in PTS after the given surgical intervention. Seven of 11 studies found improvement in all anatomic measures assessed, 2/11 studies found anatomical improvement in valve competence and patency but no hemodynamic improvement, 1/11 studies showed no anatomical improvement and 1/11 studies did not discuss anatomical outcomes. The same 10 of 11 studies also reported clinical improvement over the follow-up period, with rates of ulcer healing ranging from 50–100%. Eight of 11 studies (representing 264 patients) reported safety outcomes; no instances of mortality or pulmonary embolism were reported. Complications reported most frequently were hematoma/seroma formation and wound infection. One study that examined transplantation of cryopreserved venous valve allografts found no improvement in PTS after surgery and had a complication rate of 12/25 (48%).Important limitations of the studies reviewed included a lack of randomized controlled trials, absence of control groups, small sample sizes, short follow-up periods, retrospective data collection, imprecise definition of PTS, heterogeneity of study participants with regard to use of anticoagulants, comborbidities and DVT risk factors and in three studies, lack of reporting on procedure safety. Conclusion:PTS is a frequent and chronic condition for which treatment advances are clearly needed. Surgical treatment of moderate to severe PTS to reduce venous valvular reflux and/or improve venous obstruction could have the potential to be effective where conservative and medical treatments have failed. Our review describes studies of surgical techniques that have been used to treat PTS, but highlights important limitations of such studies. Further research using stricter research methodology is needed to evaluate the potential role of surgical techniques for the treatment of moderate to severe PTS. Disclosures:No relevant conflicts of interest to declare.

Post-thrombotic syndrome: prevention is better than cure

Post-thrombotic syndrome (PTS) can be debilitating to patients and have a major economic impact on health-care services. It arises after deep venous thrombosis (DVT) due to residual venous obstruction or valvular reflux, leading to increased venous pressure in the microcirculation. While the inflammatory process at the time of DVT may aid thrombus resolution, it may also promote destruction of venous valves. The diagnosis of PTS is principally clinical and patients typically complain of leg heaviness, swelling, pain, itching, cramps, ulcer and signs of lipodermatosclerosis. Several clinical scales or classifications have been used but it is recommended that Villalta scale is the most suitable. Risk factors for PTS include a proximal DVT and recurrent thrombosis as well as obesity and prior varicose veins. Poor quality of anticoagulation control may also be a factor. Established PTS is usually managed along the same lines as chronic venous hypertension with compression therapy and leg elevation. Surgery has only a limited role but may benefit some patients. Further trials are desperately needed to define the role of acute thrombolysis and mechanical thrombectomy, which seem to be promising treatments in the studies to date. For patients who have had a DVT more attention should be given to prescribing and using compression hosiery.

Relation between D-dimer level, venous valvular reflux and the development of post-thrombotic syndrome after deep vein thrombosis.

The pathophysiology of post-thrombotic syndrome (PTS) is postulated to involve persistent venous obstruction and venous valvular reflux. To study the association between D-dimer level, valvular reflux and the PTS in a well-defined cohort of deep vein thrombosis (DVT) patients. Consecutive patients with acute symptomatic DVT were recruited at eight centers and were followed for 24months. D-dimer was measured at 4months. A standardized ultrasound assessment for popliteal valvular reflux was performed at 12months. Using the Villalta scale, patients were assessed for PTS during follow-up by evaluators who were unaware of D-dimer or reflux results. Three hundred and eighty-seven patients were recruited; of these, 305 provided blood samples for D-dimer and 233 had a 12-month reflux assessment. PTS developed in 45.1% of subjects. Mean D-dimer was significantly higher in patients with vs. without PTS (712.0 vs. 444.0μgL(-1) ; P=0.02). In logistic regression analyses adjusted for warfarin use at the time of D-dimer determination and risk factors for PTS, D-dimer level significantly predicted PTS (P=0.03); when stratifying for warfarin use at the time of blood draw, adjusted odds ratio (OR) for developing PTS per unit difference in log D-dimer was 2.33 (95% CI 0.89, 6.10) in those not on warfarin vs. 1.25 (95% CI 0.87, 1.79) in those on warfarin. Ipsilateral reflux was more frequent in patients with moderate-to-severe PTS than in patients with mild PTS (65% vs. 40%, respectively; P=0.01) and was independently associated with moderate-to-severe PTS in logistic regression analyses (P=0.01). D-dimer levels, measured 4months after DVT in patients not on warfarin, are associated with subsequent development of PTS. Venous valvular reflux is associated with moderate-to-severe PTS.

The Relationship Between D-Dimer Level, Venous Valvular Reflux and Development of the Post-Thrombotic Syndrome after Deep Venous Thrombosis.

Background: The pathophysiology of the post-thrombotic syndrome (PTS) is postulated to involve persistent venous thrombosis and valvular reflux. We prospectively studied if d-dimer levels or valvular reflux were associated with subsequent development of the PTS after objectively confirmed deep venous thrombosis (DVT).Methods: Consecutive patients with objectively diagnosed acute symptomatic DVT were recruited at 8 hospital centres in Quebec and Ontario, Canada. Patients attended study visits at Baseline, 1, 4, 8, 12, and 24 months. Blood was taken to measure d-dimer (VIDAS d-dimer; cut off <500 ug/L) at the 4 month visit. A standardized ultrasound assessment for popliteal venous valvular reflux was performed at the 12 month visit. Standardized assessments for PTS (using Villalta scale) were performed at each follow-up visit. Subjects were classified as having developed PTS if the ipsilateral Villalta score was >5 on at least 2 visits starting at the 4 month visit or later or was >5 at the final follow-up visit. Statistical analyses assessed associations between d-dimer level, ipsilateral reflux and PTS.Results: 387 patients were recruited and followed. Mean age was 56 years and 51% were male. PTS developed in 45% of patients. Mean d-dimer was significantly higher in patients who developed PTS compared with those who did not (712.0 vs. 444.0 ug/L; p= 0.02). In logistic regression analyses adjusted for age and warfarin use at the time of d-dimer determination, d-dimer levels significantly predicted PTS (p=0.03). Ipsilateral venous valvular reflux was more frequent in patients with moderate/severe PTS than in patients with no PTS or mild PTS (65% vs. 40% vs. 43%, respectively; p=0.013). Finally, mean d-dimer was higher in patients who developed recurrent VTE during follow-up (n=31) than in those who did not (1126.8 vs. 514.9 ug/L; p=0.05), and d-dimer was an independent predictor of recurrent VTE (p=0.04) after adjustment for other known predictors of recurrence.Conclusion: D-dimer levels measured 4 months after DVT are associated with subsequent development of PTS and are predictive of VTE recurrence. Venous valvular reflux was associated with moderate/severe PTS. Further studies are required to assess whether d-dimer or valvular reflux may be useful in determining which patients are most at risk of developing PTS or severe PTS and who may thus benefit from preventive strategies.

The post-thrombotic syndrome - a condition to prevent

The incidence of the post-thrombotic syndrome (PTS) is increasing along with the incidence of deep vein thrombosis (DVT). The overall frequency of PTS ranges from 20 percent to 50 percent of DVT patients; severe PTS, which includes leg ulcers, occurs in a quarter of cases. Because of its severity and chronicity, PTS is associated with great morbidity and cost. Its diagnosis is primarily based on the presence of typical symptoms and signs, but objective evidence of venous valvular reflux can help to confirm the diagnosis. Because therapeutic options for PTS are extremely limited and results are often disappointing, prevention, recognition of clinical signs or complications, and early treatment remain the keys to reducing its morbidity. The prevention of DVT recurrence by anticoagulation and use of graduated compression stockings is likely to reduce the risk of PTS. There is no proven role for thrombolysis in preventing PTS.

Recommended reporting standards for endovenous ablation for the treatment of venous insufficiency: Joint Statement of the American Venous Forum and the Society of Interventional Radiology

Sanjoy Kundu, MD, FRCPC, FCIRSE, FASA, Fedor Lurie, MD, Steven F. Millward, MD, FRCPC, FSIR, Frank Padberg Jr, MD, Suresh Vedantham, MD, Steven Elias, MD, Neil M. Khilnani, MD, William Marston, MD, John F. Cardella, MD, FSIR, FACR, Mark H. Meissner, MD, Michael C. Dalsing, MD, Timothy W.I. Clark, MD, FSIR, and Robert J. Min, MD, MBA, FSIR, Toronto and Peterborough, Ontario, Canada; Honolulu, Hawaii; Newark and Englewood, NJ; Saint Louis, Mo; New York, NY; Chapel Hill, NC; Springfield, Mass; Seattle, Wash; and Indianapolis, Ind

Treatment of chronic venous insufficiency

Chronic venous insufficiency (CVI) results from venous hypertension secondary to superficial or deep venous valvular reflux. Treatment modalities are aimed at reducing venous valvular reflux, thereby inhibiting the ensuing pathologic inflammatory process. Compression therapy using pumps, bandaging, and/or graded compression stockings is the mainstay of treatment for CVI. Compression therapy has been shown to be effective in reducing venous hypertension retarding the development of inflammation and pathologic skin changes. Pharmacologic agents such as diuretics and topical steroid creams reduce swelling and pain short term but offer no long-term treatment advantage. Herbal supplements may reduce the inflammatory response to venous hypertension, but are not licensed by the US Food and Drug Administration, and vary in their efficacy, quality, and safety. However, several randomized controlled trials using the herbal horse chestnut seed extract containing aescin have shown short-term improvement in signs and symptoms of CVI. Endovascular and surgical techniques aimed at treatment of primary and secondary venous valvular reflux have been shown to improve venous hemodynamics promoting healing of venous ulcers and improving quality of life. The newer endovascular treatments of varicose veins using laser, radiofrequency ablation, and chemical foam sclerotherapy show some promise.

Comparison of Performance of Two Clinical Scales To Diagnose the Post-Thrombotic Syndrome: Correlation with Patient-Reported Disease Burden and Valvular Reflux.

Background and Objectives: There is no objective, criterion standard test to diagnose the post thrombotic syndrome (PTS). Two clinical scales have been used to classify deep vein thrombosis (DVT) patients as having or not having the PTS: the Villalta scale and the Ginsberg measure. Differences in test characteristics of these measures could help explain differing rates of PTS reported after DVT. During a Canadian prospective cohort study of long-term outcomes after DVT (The VETO Study), we carried out a substudy to evaluate agreement between the Villalta and Ginsberg measures with regard to (1) proportion of patients classified as having PTS; (2) relation to patient-reported quality of life (QOL); and (3) correlation with venous valvular reflux, a physiological indicator of chronic venous disease.Methods: For this substudy, 259 VETO patients were assessed for ipsilateral PTS at the 1 year follow-up visit using both the Villalta scale (grades the severity of 5 symptoms and 6 signs from 0–3; a summed total score of ≥5 indicates PTS, and >14 or presence of ulcer indicates severe PTS) and the Ginsberg PTS measure (PTS defined by the presence of daily leg pain and swelling for ≥ 1 month, occurring 6 months or more after DVT, made worse by standing/walking and relieved by rest/leg elevation). Patients also completed generic (SF-36) and disease-specific (VEINES-QOL) QOL questionnaires and underwent a standardized ultrasound assessment for ipsilateral popliteal venous valvular reflux. We compared the proportion of patients classified as having PTS with each measure and assessed associations with QOL and valvular reflux.Results: Proportion of patients classified as having PTS was 96/259 (37%) (5/96 severe) with the Villalta scale and 21/259 (8.1%) with the Ginsberg measure (kappa 0.22; 95% CI 0.13, 0.32). Agreement between measures was better for severe PTS than for any PTS. For both measures, generic and disease specific-QOL scores were significantly lower (i.e. poorer QOL) in patients with vs. without PTS; however, QOL was worse in patients with Ginsberg-PTS than in patients with Villalta-PTS. Reflux was not significantly associated with PTS for either measure.Conclusions: The proportion of patients classified as having PTS was more than 4-fold higher with the Villalta measure than with the Ginsberg measure. While both measures showed a graded association with QOL, patients with Ginsberg-PTS had poorer QOL and higher mean Villalta scores, indicating that the Ginsberg measure identifies more severe disease. The presence of reflux was not discriminating for the diagnosis of PTS with either measure.Comparison of Villalta and Ginsberg PTS measuresVillalta PTSGinsberg PTSMean (SD)YESNOpYESNOpVillalta score8.3 (3.1)1.6 (1.4)<.00019.2 (3.5)3.6 (3.4)<.0001SF-36 MCS (mental)49.5 (12.1)54.2 (8.3).000747.3 (12.6)52.9 (9.7)0.01SF-36 PCS (physical)39.7 (11.0)49.1 (10.0)<.000135.0 (12.4)46.8 (10.8)<.0001VEINES-QOL48.6 (6.1)56.2 (2.5)<.000144.1 (5.6)54.2 (5.1)<.0001Reflux present (%)54.6%44.0%0.1252.6%46.2%0.59

La chirurgie des reflux veineux profonds des membres inférieurs

Resume La chirurgie des reflux veineux profonds (RVP) date de plus de 30 ans, mais son efficacite reste encore discutee probablement par ce qu’elle est le plus souvent combinee avec la chirurgie de l’insuffisance veineuse superficielle et/ou des perforantes. Au plan etiologique c’est le syndrome post-thrombotique qui est le plus frequent, mais le RVP primitif est souvent occulte. L’agenesie valvulaire est une etiologie rarissime. Les techniques chirurgicales qui visent a traiter les RVP peuvent etre classees en 2 groupes : celles qui necessitaient une phlebotomie et celles sans phlebotomie. Dans le 1er groupe, on recense les valvuloplasties internes, les transpositions, les transplantations, les neo-valves et les allogreffes cryopreservees. Dans le second, on rassemble les manchonnages, l’intervention de Psathakis II, les valvuloplasties externes (transparietale, transcommissurale) assistees par angioscopie ou non et les dispositifs introduits par voie percutanee. L’examen clinique ne permet pas toujours de differencier les insuffisances veineuses superficielles des insuffisances veineuses profondes et parmi celles-ci les insuffisances primaires des insuffisances secondaires c’est-a-dire post-thrombotiques. Au plan des investigations, l’echo-Doppler fournit a la fois des informations anatomiques, etiologiques et hemodynamiques. Les plethysmographies volumiques permettent de quantifier la severite globale de l’insuffisance veineuse, mais ne fournissent pas d’element sur l’etiologie et ne permettent pas de facon fiable de determiner la responsabilite du systeme veineux. Si une chirurgie du RVP est envisagee, il faut completer ces investigations par une mesure des pressions et des phlebographies ascendante et descendante sachant qu’en presence de contre-indications a la chirurgie, elles ne doivent pas etre entreprises. L’objectif de la chirurgie du RVP est de corriger ce mecanisme physiopathologique responsable d’une augmentation permanente de la pression veineuse, mais on doit garder en memoire que le RVP est le plus souvent associe a un reflux dans le reseau veineux superficiel et/ou dans les perforantes, en consequence il faut corriger ces 3 anomalies. Les resultats de la chirurgie du RVP sont difficiles a estimer dans la mesure ou elle est le plus souvent associee a la chirurgie de l’insuffisance veineuse superficielle et/ou des perforantes, bien qu’assez souvent celles-ci aient ete realisees prealablement. Dans les RVP primitifs la valvuloplastie, l’intervention la plus souvent realisee, est creditee a 5 ans et au-dela de 70 % de bons resultats cliniques et hemodynamiques. Dans les syndromes post-thrombotiques une meta analyse au-dela de 5 ans des transpositions et des transplantations estime les bons resultats cliniques et hemodynamiques a 50 %. Les resultats des autres techniques sont plus difficiles a apprecier. Les indications de la chirurgie du RVP reposent sur des elements cliniques, hemodynamiques et d’imagerie. L’etiologie est egalement un facteur de decision, sachant que la chirurgie sera plus volontiers proposee dans les reflux primaires. La chirurgie du RVP ne doit etre entreprise que par des equipes specialisees dans ce domaine.

Anatomy, physiology and venous ulceration.

For many years it was believed that disease within the deep venous system, such as a deep vein thrombosis or post-phlebitic limb, was the main cause of venous ulceration. There is, however, increasing awareness of the impact of both deep and superficial venous valvular incompetence and reflux on the aetiology and healing of venous ulceration. It is now widely accepted that superficial venous disease alone can result in increased venous pressure at the ankle and subsequent skin damage and ulceration.

Venous valvular reflux in veins not involved at the time of acute deep vein thrombosis.

The aim of this study was to determine whether, in lower extremities with documented episodes of acute deep venous thrombosis (DVT), incompetence develops in veins that were not the site of thrombosis. Patients were monitored with serial duplex ultrasonography at 1 day, 1 week, 1, 3, 6, 9, and 12 months, and then annually after detection of acute DVT. The following venous segments were analyzed: common femoral, greater saphenous, proximal superficial femoral, deep femoral, popliteal, and posterior tibial. The incidence of reflux development in both thrombosed and uninvolved segments was determined. Reflux was categorized as either transient or permanent. A total of 227 limbs in 188 patients were serially studied. Mean follow-up was 19.9 months (range 1 to 88 months). Overall, 403 of the 1423 segments (28.3% +/- 2.3%) developed reflux during the study, of which 118 (29.3% +/- 4.4%) had no prior or concurrent history of thrombosis. Considering only the segments that developed incompetence, the percent without prior thrombosis at each level was as follows: common femoral vein (40.0%), greater saphenous vein (53.1%), deep femoral vein (20.6%), proximal superficial femoral vein (23.9%), popliteal vein (8.9%), and posterior tibial vein (31.9%). Valvular insufficiency developing in segments uninvolved with thrombus was more likely to be transient (40.2%) than was the reflux in thrombosed segments (22.6%). This difference was statistically significant (p < 0.05). Permanent venous valvular damage can occur in the absence of thrombosis after DVT. Reflux in uninvolved venous segments has a different anatomic distribution and is more likely to be transient than the incompetence associated with thrombosis.

Chronic venous insufficiency.

The consequences of chronic deep venous insufficiency are a major medical concern and result in significant loss of human productivity in addition to a significant compromise of lifestyles. The postphlebitic syndrome of chronic venous stasis and ulceration is a result of chronic venous hypertension and reflects a sequela of events occurring secondary to venous valvular insufficiency and reflux. Diagnostic techniques have advanced considerably; however, the prevention and management of this entity continue to be inadequate. Many new areas are being explored, both from a medical and a surgical perspective, and it is hoped that as clinical investigation proceeds, new conceptual approaches and techniques will arise to combat this difficult medical problem. The literature reviewed in this article reflects a spectrum of research attempting to understand the basic underlying hemodynamic as well as cellular and tissue changes that contribute to the development of postphlebitic signs and symptoms. More investigation is needed to enable us to proceed from the descriptive understanding of this entity to the mechanisms that result in this disease state. Preventive and curative management needs to succeed the current palliative approach to therapy.

Refinements in the ultrasonic detection of popliteal vein reflux

Color-flow and duplex ultrasonography were used to determine the optimal method for documenting venous valvular reflux. Popliteal veins were examined in 10 normal limbs and 11 limbs with clinical evidence of chronic venous insufficiency (CVI). Peak reflux velocity (spectral) and duration of reflux (spectral and color) were measured with the patient in supine and standing positions, with manual and pneumatic compression applied sequentially to thigh and calf. Manual and pneumatic compression produced equivalent reflux velocity and duration. In normal limbs peak reflux velocity was always less than 22 cm/sec, with a mean reverse flow duration of 0.3 sec ± 0.03 (SEM). In limbs with CVI, reflux velocity varied widely among protocols. Reflux duration and velocity were greater in the supine position than in the standing position for both normal limbs and limbs with CVI (p < 0.04). Duration was significantly increased for thigh versus calf compression in normal limbs (p < 0.001) but decreased in limbs with CVI (p < 0.003). Methods that used thigh compression or supine position were less capable of discriminating normal limbs from limbs with CVI. Standing calf compression provided the greatest rates of sensitivity (91%), specificity (100%), and accuracy (95%). Compared with spectral Doppler scanning, color-flow ultrasonography produced a consistently shorter reflux duration (p < 0.001). In limbs with CVI with a mean spectral duration of 2.5 sec ± 0.2 (SEM), mean color Doppler duration was 0.7 sec shorter. Our results demonstrate that popliteal vein incompetence is identified optimally by reflux duration after standing calf compression; adequate manual compression is sufficient to identify reflux; color-flow Doppler ultrasonography may underestimate reflux duration.

Quantitative segmental evaluation of venous valvular reflux with duplex ultrasound scanning.

The duration of deep venous valvular reflux was studied in 192 venous segments of the legs of 32 patients in good health. Three methods were used to elicit reflux in the supine and upright positions--Valsalva's maneuver, proximal limb compression, and release of distal limb compression. Standardized compressions were achieved with pneumatic cuffs. When this approach was used to study valve function, the time to complete closure of the valve and cessation of retrograde flow was found to be shorter than that for conventional methods of closure. The distal cuff deflation method is the only one that permits a quantitative and reproducible method to measure duration of venous reflux at all levels of the lower limb. Normal values obtained with this test are presented for the common femoral, deep femoral, and superficial femoral veins and for the popliteal and posterior tibial veins midway between knee and ankle level and the posterior tibial vein at the ankle. In the popliteal vein, median duration of reflux is 0.19 second; 95% of the values in the popliteal vein are less than 0.66 second. In distal areas, duration of reflux is short and uniform. The advantage of the cuff deflation test over the Valsalva method is that the cuff method is not hindered by the presence of ileofemoral valves. A better understanding of the relative importance of deep valve dysfunction at different levels and the expected benefit of valve repair may be obtained with this test.

Quantitative segmental evaluation of venous valvular reflux with duplex ultrasound scanning

The duration of deep venous valvular reflux was studied in 192 venous segments of the legs of 32 patients in good health. Three methods were used to elicit reflux in the supine and upright positions—Valsalva's maneuver, proximal limb compression, and release of distal limb compression. Standardized compressions were achieved with pneumatic cuffs. When this approach was used to study valve function, the time to complete closure of the valve and cessation of retrograde flow was found to be shorter than that for conventional methods of closure. The distal cuff deflation method is the only one that permits a quantitative and reproducible method to measure duration of venous reflux at all levels of the lower limb. Normal values obtained with this test are presented for the common femoral, deep femoral, and superficial femoral veins and for the popliteal and posterior tibial veins midway between knee and ankle level and the posterior tibial vein at the ankle. In the popliteal vein, median duration of reflux is 0.19 second; 95% of the values in the popliteal vein are less than 0.66 second. In distal areas, duration of reflux is short and uniform. The advantage of the cuff deflation test over the Valsalva method is that the cuff method is not hindered by the presence of ileofemoral valves. A better understanding of the relative importance of deep valve dysfunction at different levels and the expected benefit of valve repair may be obtained with this test.