Evaluation of methods for detecting venous reflux. Perspectives in venous insufficiency

Prevalence and incidence of venous leg ulcers-A systematic review and meta-analysis

Venous leg ulcers (VLU) represent a major public health challenge. Little is known about the prevalence and incidence of VLU internationally. Published studies are usually reporting different estimates because of disparities in study designs and measurement methods. Therefore, we conducted a systematic literature review and meta-analysis to identify the prevalence and incidence of VLU internationally and to characterise the population as reported in these studies. Studies were identified from searches in Medline (PubMed), CINAHL Complete (EBSCOhost), Embase, Scopus, Web of Science, LiSSa (Littérature Scientifique en Santé), Google Scholar and Cochrane Database of Systematic Reviews up to November 2022. Studies were included if their primary outcomes were reported as a period prevalence or point prevalence or cumulative incidence or incidence VLU rate. Fourteen studies met the inclusion criteria, 10 reporting estimates of prevalence, three reporting both prevalence and incidence estimates and one incidence. All were included in meta-analyses. The results show a pooled prevalence of 0.32% and a pooled incidence of 0.17%. Our results highlighted an extreme heterogeneity across effect sizes for both prevalence and incidence, which prevent a meaningful interpretation of pooled indexes and argue for further studies with specific prevalence-type reported and target population under study.

The evidence supporting treatment of reflux and obstruction in chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel convened to assess the evidence supporting treatment of chronic venous disease. Several societies addressed the questions posed to the panel. A multidisciplinary coalition, representing nine societies of venous specialists, reviewed the literature and presented a consensus opinion regarding the panel questions. The purpose of this paper is to present our coalition's consensus review of the literature and recommendations for chronic venous disease.

Clinical Tests Combined with Color Doppler Versus Color Doppler Alone in Identifying Incompetent Perforator Veins of the Lower Limb: A Prospective Analytical Study

Background The color Doppler, a better investigation to identify the perforators objectively has replaced the clinical examination for the same. However, this has led to a significant number of negative explorations and cosmetic disfigurement. Objective To compare the efficacy of the clinical tests combined with the color Doppler versus color Doppler alone to identify the perforator incompetence during the surgery for primary varicose veins of the lower limb. Methods This was a prospective analytical study, including 61 lower limb varicose vein patients who belonged to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class four-six, planned for the surgical treatment for perforator incompetence, excluding those requiring additional vascular or nonvascular procedure, recurrent varicose veins and those who had injection sclerotherapy prior to the surgery. The clinical tests, including Trendelenburg's test, multiple tourniquet tests and, the Fegan's tests were performed and incompetent perforators were marked on a template as 'C' to indicate the clinically positive perforator incompetence. The patients were then examined with the color Doppler ultrasound and the pathological incompetent perforators were marked as 'D'. The surgical management of the perforator incompetence was done by stab ligation. The incision was made in the color Doppler 'D' marked sites as it has been the standard protocol. The number of incompetent perforators identified during the surgical exploration were categorized as 'D' positive or 'C' and 'D' positive and were recorded in the specified proforma. Results It was found that the mean number of the perforator incompetence identified by the color Doppler alone was 8.2 whereas during the surgery, only a mean of six perforators was identified, leading to 20 unnecessary explorations per 10 patients (8.2 vs. 6; mean difference 2.229; P <0.001). The mean number of the perforator incompetence identified by the color Doppler combined with the clinical tests was 4.5 and during the surgery, a mean of four perforators was identified (4.5 vs. 4; mean difference 0.377; P <0.001). The color Doppler combined with the clinical examination lead to only four unnecessary explorations per 10 patients. Conclusion A combination of both the clinical tests and the color Doppler ultrasound has a higher accuracy in detecting perforator incompetence and can reduce the number of negative explorations by the rate of 16 unnecessary explorations per 10 patients.

Chronic Venous Insufficiency

Varicose veins are a common manifestation of chronic venous disease and affect approximately 25% of adults in the western hemisphere. The historical standard treatment has been surgery, with high ligation and stripping, combined with phlebectomies. In the past decade, alternative treatments such as endovenous ablation of the great saphenous vein (GSV) with laser, radiofrequency ablation, and ultrasonography-guided foam sclerotherapy have gained popularity. Performed as office-based procedures using tumescent local anesthesia, the new minimally invasive techniques have been shown in numerous studies to obliterate the GSV, eliminate reflux, and improve symptoms safely and effectively.

Chronic venous insufficiency: clinical assessment and patient selection

Chronic venous insufficiency is a complex condition, with widely varied clinical manifestations, etiologies, and underlying pathophysiology. An orderly workup is mandatory to assess the nature of a patient's underlying venous disease. This begins in the office setting with a careful medical history, physical examination, and bedside diagnostic tests. These are augmented by confirmatory diagnostic testing, including duplex ultrasonography, venography, plethysmography, and ambulatory venous pressure measurement. Based upon the results of these examinations, the patient's venous disease can be classified according to standardized classification schemes, which in turn leads to the selection of an appropriate treatment strategy. This article outlines the steps in the clinical assessment and classification of patients with chronic venous insufficiency.

Effect of Superficial Venous Surgery on Venous Function in Chronic Venous Insufficiency

Patients with chronic venous insufficiency often have combined superficial and deep venous incompetence. The aims of this study were to determine the effects of superficial venous surgery (SVS) on deep venous haemodynamics and on ambulatory venous pressure (AVP) and to determine if the AVP tourniquet test can predict the effect of SVS. Of 119 legs, 42 legs (32 subjects) with chronic venous insufficiency, healed ulceration, or active ulceration and with combined superficial and deep incompetence underwent preoperative duplex imaging and AVP measurement followed by appropriate SVS. Four months later, all underwent postoperative duplex imaging and AVP measurement. The pressure relief index (PRI) was calculated from the AVP measurement as an overall assessment of venous function. Seventeen of 119 (14%) showed no tourniquet improvement in PRI and were therefore excluded from SVS. Of those suitable for SVS, median (range) age was 56 (32-78) years. Twenty-two limbs underwent long saphenous surgery, four limbs short saphenous surgery, and 16 limbs both, based on duplex findings. Segmental deep incompetence resolved in 11/21 (52%) limbs after surgery compared to 6/21 (29%) with multisegment incompetence. Median (range) PRI improved from 319 (4-1,600) preoperatively to 1,300 (360-2,670) postoperatively (p < 0.001, Wilcoxon). PRI with thigh tourniquet correlated with postoperative PRI (r = +0.828, p = 0.01, Spearman), as did calf tourniquet (r = +0.996, p = 0.004) and both tourniquets (r = 0.535, p = 0.046). The majority of patients with combined superficial and deep incompetence can be selected for SVS on the basis of AVP measurement with tourniquets. SVS can improve segmental deep incompetence and PRI in those properly selected.

Teste de Valsalva ortostático no refluxo venoso

OBJETIVO: Determinar se a modificação proposta pelos autores no teste de Valsalva proporcionou ganho de sensibilidade, especificidade e acurácia no diagnóstico do refluxo em relação ao teste realizado na posição supina, quando comparados com a flebografia, utilizada como padrão-ouro. MÉTODO: Cento e sessenta e um pacientes com insuficiência venosa crônica (C4, 5 ou 6E P A SDP P R ) foram examinados prospectivamente. Os pacientes foram submetidos à avaliação hemodinâmica, incluindo o teste de Valsalva supino padrão e o novo teste de Valsalva ortostático. A flebografia descendente foi utilizada como padrão-ouro, com a qual os testes foram comparados. Foi criada uma curva ROC (Receiver Operator Characteristic) para determinação do limite superior da normalidade do novo teste. Os valores obtidos para sensibilidade, especificidade e acurácia de cada um dos testes foram comparados entre si, utilizando o teste de comparação de porcentagens de Dunn. Foi adotado o nível de significância de 5%. RESULTADOS: O teste de Valsalva supino padrão atingiu uma sensibilidade de 65%, especificidade de 81% e acurácia de 66%, enquanto o teste de Valsalva ortostático atingiu uma sensibilidade de 80% (P < 0,01), especificidade de 63% (P = 0,43) e acurácia de 78% (P < 0,05). CONCLUSÃO: A modificação no teste de Valsalva proposta pelos autores determinou melhor sensibilidade e acurácia, sem decréscimo significante na especificidade, provando ser útil na avaliação do refluxo da insuficiência venosa crônica.

Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR study)--haemodynamic and anatomical changes

BACKGROUND

The aim of this study was to evaluate the anatomical and haemodynamic effects of superficial venous surgery and compression on legs with chronic venous ulceration.

METHODS

Legs with open or recently healed ulceration and saphenous reflux were treated with multilayer compression bandaging or superficial venous surgery plus compression as part of a clinical trial. Venous duplex imaging was performed before treatment and at 1 year. Legs were stratified before surgery as having no deep reflux, segmental deep reflux or total deep reflux. Venous refill times (VRTs) were calculated before treatment and at 1 year using photoplethysmography, with and without a narrow below-knee cuff inflated to 80 mmHg.

RESULTS

Of 214 legs investigated, 112 were treated with compression and 102 with compression plus surgery. Saphenous surgery abolished deep reflux in ten of 22 legs with segmental deep reflux and three of 17 with total deep reflux. Overall median (range) VRT increased from 10 (3-48) to 15 (4-48) s 1 year after surgery (P < 0.001). Preoperative change in VRT on application of a below-knee tourniquet correlated with actual change in VRT following surgery.

CONCLUSION

Superficial venous surgery resulted in a significant haemodynamic benefit for legs with venous ulceration despite co-existent deep reflux; residual saphenous reflux was common.

Prospective evaluation of chronic venous insufficiency based on foot venous pressure measurements and air plethysmography findings

PURPOSE

The purpose of this study was to evaluate lower extremity venous function in patients with chronic venous insufficiency, with foot venous pressure (FVP) measurements and air plethysmography (APG).

METHODS

Eighty-five limbs of 63 patients with a history of chronic venous insufficiency (CVI) from 1995 to 1999 were studied. FVP parameters studied included ambulatory venous pressure (AVP), percent decrease in FVP with manual calf compression (%drop), ratio of increase in FVP over 4 seconds after release of compression (4SR%), and time to 90% recovery of FVP were measured. APG parameters studied included functional venous volume, 90% refilling time (VFT90), venous filling index, ejection fraction, and residual volume fraction.

RESULTS

Venous filling index and 90% refilling time were significantly decreased in limbs with stasis syndrome compared with the control group. AVP, %drop, and 4SR% also showed significantly decrease in limbs with stasis syndrome compared with those without it. AVP, %drop, and 4SR% were significantly different for the primary group compared with the secondary group, whereas no differences were found with regard to any APG parameter.

CONCLUSIONS

APG enables prediction of the presence of CVI, whereas FVP measurements are more useful for evaluation of clinical severity of CVI.

Chronic venous insufficiency: the genetic influence

Many contributing factors are involved in the genesis of varicose disease of the lower limbs such as age, sex, heredity, sedentary life style among others. For physicians the decisive role played by heredity leaves no doubt. Few studies have, however, attempted to prove the importance of the hereditary factor on a clinical level, and no study has been conducted in molecular genetics. The impact of the hereditary factor is variably estimated and its nature is open to discussion. Despite the numerous limits of the research focusing on the hereditary aspect of varicose disease, the authors can nevertheless claim that the genetic factor definitively exists and has a great impact. There are few studies conducted among twins. The data collected in these studies point to the reality of various types of heredity. With the predominant impact of the hereditary factor, and despite the role played by environmental factors, it can be supposed that a single genetic anomaly may be the determining factor of the disease in a given family. Thus we have conducted an original study in order to identify one or several mutations predisposing to varicose disease, based on the approach called "reverse genetic" and linkage study. The study of a first family whose varicose disease segregates in an autosomal dominant manner allowed us to identify 3 potential loci, if we accept the hypothesis of 2 or 3 phenocopies. No candidate gene has been singled out in these regions in the first analysis. The study of a second family whose phenotype of the varicose disease is particularly homogeneous and segregates in an autosomal dominant manner did not confirm any of the previously identified loci, probably related to a genetic heterogeneity of the varicose disease. As a consequence, the second part of this study was devoted to determining the complete genotype of each individual within this family, in order to identify new loci of interest. A potential locus has just been identified. The third part of this research, currently being pursued, is devoted to the sequencing of potential genes. In parallel, the analysis of new large families is underway. The presentation will include an update on the hereditary and genetic aspects of varicose disease, and secondly identify the limits and difficulties of the genetic study of the families.

Foot venous pressure measurement for evaluation of lower limb venous insufficiency

PURPOSE

Foot venous pressure measurement is considered to be useful for assessing lower limb venous insufficiency, because venous hypertension is the main factor predisposing to venous insufficiency. In this study, we investigated the utility of foot venous pressure measurement in the evaluation of venous insufficiency.

METHODS

A total of 148 limbs of 101 patients with venous insufficiency associated with varicose veins and treated over 5 years were studied. The measurements assessed were percentage decrease in foot venous pressure with manual calf compression (%drop), rate of increase in foot venous pressure during a 4-second period after release of compression (4SR%), and time to 50% recovery of foot venous pressure (RT50).

RESULTS

A higher incidence of skin changes (clinical, etiologic, anatomic, and pathophysiologic classification classes 4 to 6) caused by venous insufficiency was associated with %drop, 4SR%, and RT50 values. Skin changes were found in more than 50% of the limbs with a %drop less than 50%, 4SR% more than 50%, or RT50 less than 4 seconds. After tourniquets were applied to occlude the superficial veins, limbs with severe below-knee deep venous reflux (%drop 60.3 +/- 14.6, 4SR% 36.7 +/- 30.2, RT50 13.9 +/- 14.7) showed significantly worse values than those with no reflux (%drop 79.9 +/- 3.2, 4SR% 8.1 +/- 3.1, RT50 48.9 +/- 17.9) or with mild above-knee reflux (%drop 77.0 +/- 5.0, 4SR% 7.1 +/- 3.2, RT50 46.9 +/- 26.7). After sclerotherapy or surgical treatment, including deep venous reconstruction for severe below-knee reflux, all limbs showed significant improvement in clinical manifestations and foot venous pressure values (%drop 68.1 +/- 7.5 to 76.5 +/- 5.8, 4SR% 33.1 +/- 12.9 to 12.7 +/- 7.6, RT50 7.5 +/- 4.2 to 20.1 +/- 6.5).

CONCLUSION

Foot venous pressure measurements showed a good correlation with clinical severity and degree of venous reflux and were very useful for evaluating the outcome of therapy for venous insufficiency.

Durability of venous valve reconstruction techniques for "primary" and postthrombotic reflux

PURPOSE

The durability of the variety of valve reconstruction techniques in "primary" reflux and postthrombotic reflux was studied.

METHODS

A total of 423 valve repairs in 235 patients with a follow-up period ranging from 1 to 12 years were analyzed. End points for assessment consisted of ulcer recurrence and Doppler competence in serial duplex examination. Multivariate analysis with Cox proportional hazards model was used.

RESULTS

Ulcer-free survival curves were similar for "primary" and postthrombotic reflux. No significant difference in ulcer recurrence was seen regardless of the technique used. Different results were obtained when valve competence instead of ulcer recurrence was used for assessment of durability. Reconstructions in "primary" reflux were more durable than those in postthrombotic reflux. Durability differences were also noted among different techniques. A cohort of posterior tibial repairs proved extraordinarily durable (0 failures in 23 repairs).

CONCLUSION

Valve reconstruction in postthrombotic reflux can yield clinical results similar to those in "primary" reflux. Although any of the several described techniques can produce similar clinical results, Doppler competence suggests the following order for choice of procedures: (1) internal valvuloplasty, (2) prosthetic sleeve in situ, (3) external valvuloplasty, and (4) axillary vein transfer.

A noninvasive screening test to detect "critical" deep venous reflux

PURPOSE

The venous filling index (VFI) was introduced as a noninvasive measure of venous valvular reflux. Because it is quantitative, identifying increasingly severe reflux should be possible. The purpose of this study is to evaluate the sensitivity and predictive value of the VFI as a predictor of phlebographically demonstrated "critical" venous reflux.

METHODS

Thirty-one limbs with suspected venous insufficiency underwent both descending phlebography and air plethysmography. Nine limbs had deep venous reflux ending above the knee on descending phlebography (group 1), and 22 limbs had "critical" deep reflux to the below-knee level (group 2). The VFI, ejection fraction, and residual volume fraction were calculated, and a tourniquet was used to distinguish superficial from deep venous reflux.

RESULTS

Three of six group 2 limbs with a VFI less than 7 had obliteration of their iliac veins. Tourniquet application improved the VFI in 13 limbs, all of which showed either phlebographic or venous duplex evidence of greater saphenous incompetence.

CONCLUSIONS

A VFI greater than 7 showed a 73% sensitivity and 100% positive predictive value of identifying "critical venous reflux." The VFI may underestimate the degree of reflux in patients with proximal venous obstruction. Improvement of venous hemodynamics with tourniquet application suggests that venous reflux might be improved in some patients by correcting superficial venous insufficiency.

Chronic venous insufficiency in a Chinese population: an anatomic and functional study by continuous-wave Doppler and photoplethysmography

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

Colour Doppler ultrasound in diagnosing venous insufficiency. A comparison to descending phlebography

OBJECTIVE

To evaluate the technique of ultrasound colour Doppler in diagnosing venous valvular incompetence in the lower leg.

DESIGN

Prospective clinical study.

SETTING

Department of clinical physiology.

MATERIALS

44 patients (56 legs) referred with a clinical diagnosis of deep venous insufficiency.

CHIEF OUTCOME MEASURES

Colour Doppler and descending phlebography.

MAIN RESULTS

Using phlebography as a "gold standard" the accuracy of the colour Doppler technique varied between 93% and 55% for the different veins. For the superficial and deep femoral veins, the popliteal vein and the long and short saphenous veins the accuracy was between 90% and 70%. The lowest correlation was found for the deep calf veins (55-66% accuracy).

CONCLUSIONS

Colour Doppler was found to be a suitable technique for non-invasive investigation of patients with suspected venous insufficiency. Since the colour Doppler technique is non-invasive it is well suited for follow-up studies. Descending phlebography should be reserved as an adjunct technique in patients scheduled for valve reconstructive surgery.

Image-directed Doppler ultrasound in the diagnosis of lower-limb venous insufficiency

Ninety-eight legs in 73 patients were evaluated with image-directed Doppler ultrasound for suspected chronic venous insufficiency. Examinations of the entire venous system were performed to determine lumen patency and valvular competence. Reflux during Valsalva maneuver in the femoral and great saphenous vein, and, after release of distal compression in the popliteal vein, indicated valvular incompetence. Twenty limbs had normal veins; Baker's cysts were found in three. Superficial venous insufficiency was found in 25 cases. Deep reflux, either alone or in combination with superficial reflux, was the predominant pathological feature (53 legs). Photoplethysmographic studies of the veins were performed on 24 limbs. Image-directed Doppler ultrasound was more successful in defining the exact site of venous incompetence and in detecting nonvenous pathology. By the combination of real-time imaging of the vein with gated Doppler sonography of flow, image-directed Doppler sonography is becoming the method of choice for the investigation of chronic venous insufficiency.

Free flap valvular transplantation for refractory venous ulceration

PURPOSE

Nonoperative therapeutic approaches to chronic venous ulceration, although effective, often require prolonged dressing care and immobilization with leg elevation. Results of skin grafting, perforator ligation, and valve interpositions and reconstructions improve results of ulcer healing but have not uniformly prevented ulcer recurrence. Our hypothesis is that reconstruction of chronic venous ulcers by excision of the diseased tissue bed and replacement with a free flap containing multiple competent microvenous valves and a normal tissue microcirculation will result in long-term cure of these debilitated patients.

METHODS

Six patients with chronic venous insufficiency and recurrent ulceration (class 3) underwent excision of ulcers and surrounding liposclerotic tissue beds and reconstruction with fasciocutaneous free flaps (two bilateral). Preoperative and postoperative photoplethysmography was used to assess venous refilling times. Duplex scanning was performed to assess deep venous reflux.

RESULTS

There were no flap failures. Photoplethysmographic venous refilling times measured on flaps demonstrated significant immediate and long-term increases from preoperative values (all results +3 by Society of Vascular Surgery outcome grading). Long-term maintenance of tissue integrity is shown by absence of recurrent ulceration and no evidence of recurrent tissue lipodermatosclerosis in all flaps at follow-up (8 months to 7.5 years; mean 24 months). No recurrent lipodermatosclerosis was seen on flap biopsy at 2 and 7 years. Separate cadaveric injection studies, including scanning electron microscopy, revealed numerous microvenous valves directed toward the draining pedicle in the flaps used for reconstruction.

CONCLUSIONS

This is the first comprehensive report providing combined laboratory and clinical evaluation, anatomic rationale, and long-term outcome of surgical rehabilitation of patients with chronic venous ulceration who have undergone microsurgical flap reconstruction.

Foot volumetry and duplex ultrasonography after saphenous and subfascial perforating vein ligation for recurrent venous ulceration

Forty-three patients undergoing superficial and perforating vein ligation for recurrent venous ulceration underwent preoperative and postoperative foot volumetry and postoperative duplex ultrasonography. Patients were followed for a median of 66 (range 18-144) months. Of nine patients who developed recurrent ulceration, six had femoral vein incompetence and all had popliteal vein incompetence demonstrated by duplex ultrasonography. Of the 34 patients who remained ulcer-free, five had femoral vein incompetence and a single patient had popliteal vein incompetence on duplex scanning, giving positive predictive values for recurrent ulceration of 55 per cent (femoral vein incompetence) and 90 per cent (popliteal vein incompetence). Patients with saphenofemoral incompetence on late follow-up were also more likely to suffer recurrence. Preoperative foot volumetry with tourniquet occlusion of superficial veins showed that the median expulsion fraction of patients who developed recurrent ulcer during follow-up was 0.8 (range 0.6-2.3) per cent compared with 1.5 (range 0.4-2.9) per cent for those who remained ulcer-free (P = 0.025); the median half-refilling time of patients with recurrent ulcer was 1.5 (range 0.5-5.5) s compared with 5.0 (range 0.5-23.0) s for those without recurrence (P < 0.01). Postoperative foot volumetry showed similar differences. Deep venous incompetence, particularly of the popliteal segment, as demonstrated by duplex ultrasonography and foot volumetry, is a useful predictor of recurrent ulceration after subfascial perforator and superficial venous ligation.

Photoplethysmography in the diagnosis of superficial venous valvular incompetence

Photoplethysmography was compared with clinical investigation combined with Doppler ultrasonography in the diagnosis of superficial venous valvular incompetence of the lower limb. In 268 consecutive patients, 536 limbs were investigated. A total of 22.1 per cent of the photoplethysmographic investigations were uninterpretable because they did not allow reliable determination of the refilling time. Agreement between clinical investigation combined with Doppler ultrasonography and photoplethysmography was found to be poor (kappa = 0.30). These results suggest that photoplethysmography is not the non-invasive method of choice for routine evaluation of superficial venous valvular incompetence of the leg.