Effect of lightweight compression stockings on venous haemodynamics

OBJECTIVE

To investigate the effect of lightweight graduated elastic stockings on venous haemodynamics.

DESIGN

The amount of reflux and function of the calf muscle pump were evaluated before and after the application of lightweight graduated compression stockings using air-plethysmography. Each patient acted as his own control and the Wilcoxon rank sum test was used.

SETTING

Vascular laboratory of a teaching hospital.

SUBJECTS

19 female patients (20 limbs) with moderate varicose veins.

MAIN OUTCOME MEASURES

The haemodynamic parameters: amount of reflux (VFI), ejection fraction (EF) of the calf muscle pump after one tiptoe exercise, residual volume fraction (RVF) after 10 tiptoes and venous volume (VV) were determined for each patient with and without the three strengths of stocking (7, 10, 14 mmHg at the ankle) using air-plethysmography.

RESULTS

The mean VFI decreased from 5.7 ml/sec without stockings to 4.6+/-2.2, 3.9+/-2.3, and 3.4+/-1.8 with stockings of 7, 10 and 14 mmHg respectively (p<0.0002). Similarly the RVF showed a significant decrease with all three stockings from the initial value 42.3% to 36.3, 34.4 and 31.5 respectively (p<0.03). EF showed an increase from 49.2% to 51.4, 50.9 and 56, but only with the latter was the increase significant (p<0.02). VV decreased from 118.8 ml to 113.6+/-24.4 (p>0.05), 104.2+/-22.8 and 109.1+/-27.4 (p<0.008) with 10 and 14 mmHg.

CONCLUSIONS

The results indicate that lightweight compression stockings can have a significant effect on venous haemodynamics. They decrease the residual volume fraction and by inference ambulatory venous pressure. This is the result of an increase in the ejection fraction with a decrease of reflux. The results offer a possible physiological explanation on the relief of symptoms experienced when patients with varicose veins wear lightweight stockings.

Long-term results of lower-extremity venous injuries

OBJECTIVES

To compare the long-term venous function of ligated, simple, and complex repairs and to assess long-term patency in repaired veins.

DESIGN

A cohort study of patients with lower-extremity venous injuries treated during a 7-year period.

SETTING

A level I urban trauma center.

PATIENTS

Twenty-one of the 79 patients with a history of lower-extremity venous injury identified via the trauma registry consented to outpatient evaluation.

INTERVENTION

Participating patients underwent a through vascular examination that included color flow duplex venous imaging and air plethysmographic assessment.

MAIN OUTCOME MEASURES

The patency of venous repairs, the incidence of chronic deep venous thrombosis, and evidence of chronic venous insufficiency.

RESULTS

The venous injuries included 5 iliac, 10 femoral, and 6 popliteal. Six of these injuries were ligated, 11 injuries were simply repaired (lateral venorrhaphy or end-to-end), and 4 were repaired with complex interposition grafts. All repairs were patent, with no evidence of deep venous thrombosis by color flow duplex venous imaging. Seventeen of the 21 patients had symptoms, color flow duplex venous imaging findings, and air plethysmographic data consistent with chronic venous insufficiency, including significant mean differences (P < .03) in outflow fraction, outflow fraction with compression, venous filling index, and residual volume fraction, when compared with the uninjured extremity. The most profound changes followed complex repairs and perioperative fasciotomies.

CONCLUSIONS

While the long-term patency of venous repairs is excellent, most patients demonstrate evidence of chronic venous insufficiency after either ligation or repair. Complex venous repairs and fasciotomy are associated with the most severe functional changes.

Hemodynamic assessment of femoropopliteal venous reflux in patients with primary varicose veins

PURPOSE

The aim of this study was to assess the anatomic distribution and extent of deep venous reflux in patients with primary varicose veins (PVVs) and to investigate its influence on venous hemodynamics.

METHODS

Femoropopliteal venous reflux was examined using duplex color Doppler ultrasonography in 356 limbs with PVVs in 240 patients. Photoplethysmography (PPG) was performed using above-knee and below-knee tourniquets to determine the contributions of deep and superficial venous insufficiency.

RESULTS

Of 356 limbs with PVVs, 61 (17.1%) had femoropopliteal venous reflux, 42 (11.8%) had superficial femoral venous reflux alone, and 57 (16.0%) had popliteal venous reflux alone. Femoropopliteal venous reflux was associated significantly with clinical symptoms and shortened the half venous refilling time measured by PPG, especially in the presence of incompetent perforating veins. These findings were obtained regardless of the presence of long saphenous vein reflux.

CONCLUSIONS

Femoropopliteal venous reflux associated with PVVs plays an important role in the pathophysiologic mechanism of venous stasis and influences venous hemodynamics in the presence of incompetent perforating veins and short saphenous vein.

[Vascular sports in ambulatory therapy of venous circulatory disorders of the legs. Diagnostic, therapeutic and prognostic aspects]

In 33 patients with chronic venous incompetence (CVI) caused by primary varicoses or postthrombotic syndrome stage I-III (according to Widmer) the therapeutic benefit of 6 months of medically supervised physical exercise training was documented. During the training penud there was an improvement in subjective complains such as pain and tendency for edema in the legs. Mobility in the upper ankle joint was improved asuss as venous drainage function. Clinical benefit was achieved in the reduction of ulcer size; 7 of the 10 ulcers completely healed. Medically supervised physical exercise training and optimized compression therapy are basic therapeutic approaches in conservative treatment in chronic venous insufficiency. Costs are covered by the patient's health insurance company in Germany, as long as the exercise training is medically supervised.

[Biomechanical stimulation therapy as physical treatment of arthrogenic venous insufficiency]

We report about a new type of physical therapy which can be used in patients with joint immobility secondary to by chronic venous insufficiency. Biomechanical stimulation therapy (BMS) uses mechanical vibration of standardised frequencies from 18-35 Hz spectrum to expose the feet and legs to longitudinal mechanical stimuli. Therapeutic benefit and clinical improvement can be achieved after a short period of treatment. We describe a 76 year old female patient suffering from both impaired motion and recurrent venous ulceration due to chronic venous insufficiency. After 10 days treatment with BMS, mobility of upper ankle joints improved by 16 degrees and 19 degrees and was accompanied by healing of venous ulcerations after skin flap transplantation. Biomechanical stimulation methods were developed in the former Soviet Union where they were used in sports medicine to improve relaxation of strained muscle structures and to increase the stretching ability of capsules and tendons. We have successfully treated 6 patients with impaired mobility and chronic venous insufficiency. We believe that BMS is likely to become a valuable therapeutic tool in patients with this problem in the near future.

Single-visit venous ulcer assessment clinic: the first year

BACKGROUND

Venous ulceration is a significant clinical problem to both clinicians and patients. To optimize the management of patients with ulcers a single-visit, dedicated venous ulcer assessment clinic was set up.

METHODS

All patients referred to the clinic during the first year were recorded prospectively. Each patient was assessed clinically and with colour-coded venous and, where indicated, arterial duplex scanning. Ulcers were classified as venous, arterial, mixed or non-vascular on a basis of ankle:brachial pressure indices and venous duplex scanning.

RESULTS

Eighty-eight patients (104 limbs with ulcers) were assessed. Seventy-nine per cent of ulcers were venous, 2 per cent arterial, 12 per cent mixed and 7 per cent non-vascular. Of the 95 limbs with demonstrable venous reflux, reflux was confined to the superficial system in 57 per cent, the deep system in 6 per cent and was combined in 37 per cent of limbs. Of the 22 patients who reported previous deep vein thrombosis, nine had normal deep vein function. Some 38 per cent of limbs with no history of previous thrombosis had abnormal deep vein function.

CONCLUSION

In this clinic 14 per cent of leg ulcers had a significant arterial component and over half of venous ulcers may benefit from superficial venous surgery. In many ulcerated limbs, clinical assessment alone is inadequate to detect superficial reflux or previous deep vein thrombosis.

Late results of iliofemoral venous thrombectomy

PURPOSE

Although anticoagulation therapy for iliofemoral venous thrombosis prevents pulmonary embolism, it is not designed to avoid the postthrombotic syndrome. Mechanical removal of the thrombus in the form of venous thrombectomy should yield better long-term results. The purpose of our study was to analyze the clinical outcome and venous valvular function of limbs 5 to 13 years after iliofemoral venous thrombectomy.

METHODS

Seventy-seven lower extremities underwent venous thrombectomy for acute iliofemoral venous thrombosis and were monitored for a mean follow-up of 8 1/2 years (range, 5 to 13 years). Patency of the iliofemoral venous system, competence of the femoral popliteal valves, and clinical signs and symptoms of chronic venous insufficiency were evaluated in each case.

RESULTS

Subsequent to early perioperative failure, patency remained stable over time at 84%. Valvular competence was preserved in 80% at 5 years; however, it decreased to 56% at 10 years. It is important that more than 90% of the limbs had no symptoms or mild symptoms of chronic venous insufficiency.

CONCLUSIONS

Venous thrombectomy should be considered for primary treatment in selected cases of early iliofemoral venous thrombosis.

Prospective audit of surgery for varicose veins

BACKGROUND

Recent reports have demonstrated a high recurrence rate following varicose vein surgery. It has been suggested that this is due to inadequate surgery. This has been assessed by a prospective surgical audit.

METHODS

Fifty limbs in 33 patients awaiting varicose vein surgery were examined before operation and 6 weeks after operation. A duplex scanner was used to detect sites of venous incompetence.

RESULTS

Eighteen operations were performed for recurrent disease, 38 limbs had an incompetent connection between the long saphenous vein or another superficial vein and the common femoral vein in the groin, and 11 limbs had saphenopopliteal incompetence. Following surgery, persisting incompetence existed in seven limbs in the groin and eight limbs in the popliteal fossa; this was due to inadequate surgery in 13 of 15 cases. Thirty-four operations were performed by trainees who were responsible for 14 of the 15 cases of persisting incompetence in the groin or popliteal fossa.

CONCLUSION

Improved surgical technique and training is required to reduce recurrence following varicose vein surgery.

[Pathologic significance of the internal pudendal vein in the development of intrapelvic venous congestion syndrome]

BACKGROUND

The insufficient circulation of the internal pudendal vein is a characteristic sign observed in the patient with intrapelvic venous congestion syndrome (IVCS). The present study was designed to reveal the pathophysiological significance of it in IVCS.

METHODS

Twenty-seven men with IVCS and nine men without IVCS were used in this study. The circulatory status in the internal pudendal vein was evaluated by three dimensional magnetic resonance venography (3D-MRV). From the coronal MRI (the original image of 3D-MRV) on the slice of the ischiorectal fossa, the thickness of the obturator internus muscle and the pararectal fatty tissue was measured. The interval between the ischial supine, locating at the bottom of the pelvis, was also measured. Using eleven cadavers, the pelvic cavity was examined carefully in terms of the course of the internal pudendal vein.

RESULTS

The finding of interruption in the internal pudendal vein by 3D-MRV was observed at the ascending portion in all cases with IVCS. Although the thickness of the obturator internus muscle was not significantly different between two groups, the thickness of the pararectal fatty tissue in IVCS group was significantly thinner as compared to control group (3.0 +/- 0.4 vs 3.6 +/- 0.1 cm, p < 0.01). The interval between the ischial supine in IVCS group was significantly narrower as compared to control group (7.9 +/- 1.1 vs 9.4 +/- 0.5 cm, p < 0.01). In cadavers, it was confirmed anatomically that the ascending portion of the internal pudendal vein passed through the pudendal canal (the Alcock's canal) accompanied by the internal pudendal artery and the pudendal nerve.

CONCLUSIONS

It was suggested that anatomical factors, such as the thinner pararectal fatty tissue or the narrower interval between the ischial supine, might cause the development of IVCS, according to the compression of the Alcock's canal.

[Chronic venous insufficiency--from pathophysiology to therapy. 4: Treatment of ulcus cruris--therapy guidelines]

In the field of phlebology and angiology, leg ulcer represents a complex diagnostic and therapeutic problem. The initial steps include the taking of a careful history, inspection and palpation, and thorough angiological investigation which, where the individual situation makes this necessary, must be supplemented by such further diagnostic measures as biopsy, laboratory investigations or even allergy tests. Subsequent treatment must be stage-matched and must meet the individual needs of the patient. Both conservative and surgical forms of treatment are available.

[Chronic venous insufficiency--from pathophysiology to therapy. 3: Physical therapy of venous diseases]

In patients with chronic venous insufficiency (CVI), stage-oriented physiotherapy can be employed in addition to surgery, drug treatment and sclerotherapy, with both prophylactic and curative intent. Apart from improving the hemodynamic situation, physiotherapy aims in particular to preserve or reactivate the active and passive pump mechanisms of the lower limbs, for example, the calf muscle pump and the ankle pump. Consequently the wide spectrum of physiotherapeutic measures includes such measures as compression therapy, anticongestion positioning, massage and exercise, all of which can be supplemented or replaced, as didacted by the condition prevailing, by hydrotherapy, electrotherapy, balneotherapy or climatic therapy.

The development of valvular incompetence after deep vein thrombosis: a 7 year follow-up study with duplex scanning

OBJECTIVES

To study the development and progression in time of deep venous valve incompetence with Duplex ultrasonography in combination with distal cuff deflation in patients with a history of deep venous thrombosis (DVT) and to evaluate symptoms of chronic venous insufficiency (CVI).

DESIGN

Prospective cohort study.

MATERIALS AND METHODS

In a long term follow-up study the deep venous system of 24 patients (7 men, 17 women, mean age 51 years) of an initial group of 27 with phlebographically documented deep venous thrombosis were examined with Duplex scanning at two intervals (mean 34 and 86 months) after DVT.

RESULTS

All but one segments recanalised. Deep venous incompetence occurred exclusively in post-DVT segments. At first follow-up 48% of the post-thrombotic segments showed valve incompetence, while at second follow-up this had increased to 60% (p < 0.001). Venous segments of the upper leg mainly contributed to this increase. Our group of 24 patients was too small to find any significant correlation between symptoms, thrombosis and valvular incompetence.

CONCLUSIONS

The development of deep vein valve incompetence after deep vein thrombosis is a progressive process over more than 5 years.

Angiographic embolization of intrahepatic arterioportal fistula

We report the case of a posttraumatic arteriovenous fistula between the right hepatic artery and the right portal vein remarkable in that clinical manifestations, including portal hypertension and mesenteric insufficiency findings, appeared latently and progressively worsened. This hepatoportal fistula was diagnosed by Doppler sonography and successfully treated by transcatheter embolization of feeding hepatic artery branch with steel coils. We emphasize the interest of pulsed Doppler in the diagnosis of hepatoportal fistula, in assessment of hemodynamic changes related to the fistula and in follow-up after treatment.

Does total hip arthroplasty predispose to chronic venous insufficiency?

One hundred thirty-four limbs (40% retrieval) were reviewed 14 to 21 years after total hip arthroplasty. Each had been screened for deep vein thrombosis following surgery by the fibrinogen uptake test, with proximal thrombi confirmed venographically. The limbs were assessed for chronic venous insufficiency with a standard clinical grade and photoplethysmography. Clinical chronic venous insufficiency was found in 4 of 36 (12%) limbs without and 11 of 98 (11%) with previous thrombosis (chi-square = .09, P = .77). Clinical chronic venous insufficiency was detected in 9% of limbs (6/67) with calf thrombi, 0% of limbs (0/11) with isolated femoral thrombi, and 25% of limbs (5/20) with calf and femoral thrombi. After photoplethysmographic assessment, only 2 of 98 (2%) cases were thought to be attributable to thrombosis after hip arthroplasty (95% confidence interval, 0.2-7.2). Despite a high incidence of deep vein thrombosis diagnosed on the fibrinogen uptake test after total hip arthroplasty, symptomatic deep chronic venous insufficiency was an unusual outcome 14 to 21 years later.

Increased arterial inflow in extremities with chronic venous insufficiency: an important and unappreciated hemodynamic parameter

BACKGROUND

The purpose of this study was to evaluate and analyze arterial inflow (AI) in lower extremities of patients with symptoms of chronic venous insufficiency (CVI) and of members of a healthy control group.

METHODS

Foot mercury-in-silicon strain-gauge plethysmography was used to measure AI, venous reflux, and muscle pump efficiency in 388 extremities of 194 patients with symptoms of CVI. Severe stage III symptoms (Society for Vascular Surgery/International Society for Cardiovascular Surgery classification) were present in 84 extremities, moderate stage II symptoms were present in 81 extremities, and mild stage I symptoms were present in 158 extremities. No symptoms, stage 0, were found in 65 contralateral extremities of patients with unilateral symptoms. Identical parameters were measured in 70 extremities of 35 healthy subjects in a control group. AI in each staged group was compared with that of the control group and with that of the other groups with symptoms with the use of Kruskall-Wallis analysis of multiple variances.

RESULTS

The mean AI (+/-SD) in milliliters per 100 ml of foot tissue per minute in the extremities in the control group was 0.82 +/- 0.48. In the extremities without symptoms, contralateral to those with symptoms in patients with unilateral disease, the AI was 1.24 +/- 0.88. In extremities with mild symptoms the AI was 1.54 +/- 1.20, in extremities with moderate symptoms it was 2.88 +/- 1.70, and in extremities with severe symptoms it was 6.25 +/- 4.91. The AI was significantly increased in all extremities of patients with CVI (stages 0 to III) when compared with that of patients in the control group. Extremities with stage II and III disease had significantly higher AI than did extremities with stage 0 and stage I disease. The difference in AI between extremities with stage 0 and I disease was not statistically significant, and no significant difference in AI was seen between extremities with stage II and III disease.

CONCLUSIONS

When plethysmographic methods are used to evaluate extremities with CVI, high AI, if not considered, can overrepresent the true magnitude of reflux. High AI may indicate presence of primary anatomic arterioventricular fistulas, or it may be the consequence of inflammatory changes and secondary functional arterioventricular shunting. Increased AI in contralateral extremities with no symptoms may point to the role of high flow in the pathogenesis of CVI. Clarification of this question requires further investigation.

Interactions between endothelial cells and smooth muscle cells after their activation by hypoxia. A possible etiology for venous disease

Because of their localization at the interface between blood and tissue, endothelial cells are responsible for the maintenance of vascular homeostasis. They fulfil a series of various functions and constantly interact with circulating leukocytes and with the smooth muscle cells (SMC) present in the media. Any disturbance of their metabolism can thus lead to alterations of the blood vessel functions. We have shown that hypoxia, for example resulting from venous stasis, induces the activation of endothelial cells which then release inflammatory mediators able to activate neutrophils and to induce their infiltration as well as growth factors for SMC. We propose that these processes are the beginning of a cascade of events eventually leading to structural and functional modifications of the venous wall similar to the ones observed in varicose vein wall. The endothelium alterations resulting from venous stasis would thus be the origin of the development of the venous disease. Pharmacological and clinical evidence reinforce this hypothesis.

Intermittent pneumatic compression in chronic venous insufficiency favorably affects fibrinolytic potential and platelet activation

Nineteen patients with symptoms of chronic venous insufficiency (CVI) were treated with 13-week cycles of intermittent pneumatic compression (IPC) during 2 h sessions twice weekly, with most treatments at home. At study completion, quantitative subjective scores for total symptomatology were improved in 16/19 patients (84%). Enhancement of fibrinolytic potential in vivo was detected in 86% of observations on specimens from CVI patients over 2 h of IPC, with accelerated euglobulin clot lysis times (ELT) noted within 15 min of initiating compression. The enhanced fibrinolytic potential was attributed to increased urokinase plasminogen activator (u-PA), probably released from perturbed endothelial cells by IPC. Significant decreases in total t-PA antigen (mass concentration) but not t-PA activity, were produced by IPC in CVI patients only (P = 0.0001), with greater effects noted in the non-anticoagulated versus the anticoagulated cohort. Plasminogen activator inhibitor type 1 (PAI-1) levels rose rapidly after IPC only in the controls and non-anticoagulated CVI patients. PAI-1 decreased in those receiving anticoagulation. No platelet perturbation was detected during IPC by measuring levels of beta-thromboglobulin or the thromboxane A2 metabolite, 11-dehydrothromboxane B2; however, significant (P < 0.003) decreases in plasma prostacyclin (PGI2) levels (measured as the stable 6-ketoprostaglandin F-1-alpha-metabolite) were observed after 15 min of IPC in non-anticoagulated CVI patients only. There was no evidence of increased thrombin generation by IPC, determined by urinary excretion of fibrinopeptide A and prothrombin fragment 1. Concurrent anticoagulation appears to mediate more favorable biochemical alterations in CVI, although subjective improvement did not correlate with anticoagulation. The mechanism(s) by which these physiologic changes compliment the mechanical effects of IPC remain to be elucidated and will require adequately controlled and powered studies.

The venous wall and valvular function in chronic venous insufficiency

The present paper is an overview taking into account the four most important etiological factors which can be involved in the development of chronic venous insufficiency (CVI): (1) weakness of the vascular wall including connective tissue and smooth muscle, (2) dysfunction and damage of the venous endothelium, (3) damage of the venous valves and (4) disturbancies of the microcirculation. The first three can be implicated in the development of reflux and venous hypertension and it is difficult to pin-point one single factor as being the most important. Disturbancies of the microcirculation eventually lead to the typical complications of CVI. With better understanding of the disease process it is possible to attack the causative factors leading to CVI and prevent and heal complications.

[Chronic venous insufficiency]

In severe chronic venous insufficiency (CVI) the fascia cruris is increasingly involved in the pathological process. The resulting loss of compliance as a consequence of altered fascia texture leads to increased pressure in the compartments of the lower extremity, followed by reduced circulation. Arteries and nerves, which penetrate the fascia along with insufficient perforating veins, are damaged through the increased pressure and are therefore functionally impaired. Accordingly many pathological changes in the crural ulcer have their anatomical substrate here. The microcirculation is distributed by either primary varicosis with secondary insufficiency of the deep veins or by primary insufficiency of the deep venous system as seen in a post-thrombotic syndrome. Subsequent therapy should be based on this knowledge and therefore consists of medication and basic physical therapy along with dissection of the perforating veins-fasciotomy and fasciectomy combined with plastic surgery. All of the therapeutic measures have to take the stage of the CVI into consideration. In order to eliminate the insufficient perforating veins and to perform fasciotomy the endoscopic approach is considered the state of the art. In extreme cases, only fasciectomy combined with plastic surgery can lead to durable healing.