Recurrent varicose veins: correlation between preoperative clinical and hand-held Doppler ultrasonographic examination, and anatomical findings at surgery

A medial approach for open redo groin surgery for varicose vein recurrence

Aims: To describe the technique of a medial approach for redo groin surgery for varicose vein recurrence and to report the one year prospective results for this procedure.

Method: The standardised technique employed is described. Prospective one year data regarding the effectiveness of this procedure was taken from a one year audit performed 2009–2010 at Skaraborg Hospital. Details regarding this patient cohort and the surgery performed were registered. The outcome was measured by using venous clinical severity score (VCSS) and the disease specific quality of life was measured with the Aberdeen varicose vein questionnaire (AVVQ). Venous duplex ultrasound scanning (DUS) was performed preoperatively, after 4–6 weeks and after one year.

Results: Out of 255 venous operations 34 regarded redo groin surgery and these were assessed. Females dominated 25/34 and the median age was 55 years (range 26–80). All patients had a probable stump according to DUS. CEAP C3-C4 dominated 28 patients/ legs and C5-C6 in 4 legs. The median operating time was 69 minutes (range 35–120) and the operating time was significantly correlated to the number of incisions (p<0.001). The complication rate was 15 %, including 2 wound infections but no DVT or lymph leakage. Both the VCSS and the AVVQ scores were significantly improved after one year (p<0.001). After one year DUS detected recurrence in the groin was observed in 19 %, mostly neovascularisation.

Conclusion: Redo groin surgery by a standardised medial approach is a safe and not an especially technically demanding technique that can be performed reasonably rapidly. The one year results are promising and the early DUS recurrence rate seems low.

Endovenous laser treatment of groin and popliteal varicose veins recurrence

Objectives Recurrent varicose veins following surgery is a common, complex and costly problem in vascular surgery. Treatment for RVV is technically more difficult to perform and patient satisfaction is poorer than after primary interventions. Nevertheless, traditional vein surgery has largely been replaced by percutaneous office-based procedures, and the patients with recurrent varicose veins have not benefited from the same advantages. In this paper, we propose an endovascular laser treatment that allows reducing the invasiveness and complications in case of SFJ and SPJ reflux after ligation and stripping of the great and small saphenous vein. Methods 8 SFJ and 1 SPJ stumps were treated by endovascular laser treatment in out-patient clinic. Endovascular laser treatment was performed with a 1470 nm diode laser and a 400 µc radial slim™ fiber. Intraoperative ultrasoud was used to guide the fiber position and the delivery of tumescent anesthesia. The gravity of chronic venous disease was determined according to the CEAP classification and the severity of symptoms was scored according to the revised Venous Clinical Severity Score (VCSS). Results The average linear endovenous energy density was 237 J/cm. Patients return to daily activities after a mean of 1.9 days after. The VCSS improved drastically from a mean of 8 pre-interventional to 1 at day 30 and until one year. During the follow-up period (mean 8 months, range: 5-17 months), all the stumps except one were occluded. All patients were very satisfied or satisfied with the method. No severe complications occurred. Conclusions Office-based endovascular laser treatment of groin and popliteal recurrent varicose veins with 1470 nm diode laser and radial-slim fiber is a safe and highly effective option, with a high success rate in the early post-operative period.

Prevention of Sapheno-Femoral and Sapheno-Popliteal Recurrence of Varicose Veins by Forming a Partition to Contain Neovascularization

Objective:

To test the hypothesis that sapheno-femoral recurrence of varicose veins may be prevented by containment of neovascularization.

Design:

Prospective minimum 4-year follow-up by surgical exploration and morphological examination of recurrent vessels in all limbs with clinical or phlebographic evidence of sapheno-femoral recurrence.

Setting:

Varicose vein clinic of a teaching hospital.

Interventions:

Sapheno-femoral ligation and multiple ligation (group 1); sapheno-femoral ligation, interposition of cribriform fascia and multiple ligation (group 2); sapheno-femoral ligation, interposition of artificial implant and stripping (group 3).

Main outcome measures:

Incidence of sapheno-femoral recurrence.

Results:

The incidence of sapheno-femoral recurrence through neovascularization was lower ( p < 0.001) in groups 2 and 3 after containment of neovascularization at the sapheno-femoral junction by cribriform fascia or artificial implant than in group 1 after ligation alone (3% and 1% vs 25%, respectively). The incidence of recurrent or persistent varices distal to the groin was lower ( p < 0.001) after stripping (group 3, 57%) than after multiple ligation (group 1, 93%; group 2, 81%).

Conclusions:

Sapheno-femoral ligation, interposition of cribriform fascia or artificial implant at the sapheno-femoral junction, and stripping is a more effective treatment of varicose veins than sapheno-femoral ligation and multiple ligation.

Recurrent Varicose Veins and Primary Deep Venous Insufficiency: Relationship and Therapeutic Implications

Objective:

Evaluation of the relationship between deep venous insufficiency and recurrent varicose veins (RVV).

Design:

Retrospective analysis of patients affected by RVV submitted to clinical examination, continuous-wave (CW) Doppler, duplex scanning and descending phlebography in cases of incompetence at groin level.

Setting:

Department of Vascular Surgery, Istituto Dermopatico dell'Immacolata (IRCCS), Rome.

Patients:

Two hundred and thirty-nine patients affected by RVV.

Main outcome measures:

CW Doppler ultrasound, duplex ultrasound imaging and descending phlebography to assess venous incompetence.

Results:

Doppler examination revealed no reflux at the groin level in 80 limbs. In the remaining 166 limbs, descending phlebography showed a superficial venous reflux in 95 limbs (related to a sapheno-femoral junction recanalization or to an inadequate previous operation) while in 69 (28% of the 246 limbs examined) deep venous reflux was present (superficial femoral vein in 38 cases, profunda femoris vein in seven cases and both veins in 24 cases); in two cases reflux came from the pelvic veins.

Conclusions:

Our data suggest a possible role of primary deep venous insufficiency in the development of RVV and the value of descending phlebography in the planning of further surgery.

Phlebography in the Management of Recurrent Varicose Veins

Objectives:

(1) To report the results of phlebography (varicography and venography) in the identification of important venous communications in patients with reurrent varicose veins. (2) To assess whether phlebography provides additional valuable information when compared with clinical and hand-held Doppler examination.

Design:

Retrospective review.

Setting:

Vascular unit, district general hospital.

Patients:

A consecutive series of 46 patients attending with recurrent varicose veins.

Interventions:

Clinical examination, hand-held Doppler, venography and varicography.

Main outcome measures:

(1) Sites of incompetent venous communications. (2) Assessment of value of preoperative phlebography when compared with clinical and hand-held Doppler examination.

Results:

Sixty-four venograms were performed on 46 patients of mean age 52 years, range 30–81 years. Calf perforator (88%) and mid-thigh perforator incompetence (38%) were common. Groin recurrence (33%) included examples of neovascularization, inadequate previous surgery and inadequate assessment. Popliteal recurrence (34%) secondary to incompetent gastrocnemius, popliteal fossa and short saphenous veins also present. Preoperative phlebography supplied valuable additional information in 75% of Patients.

Conclusion:

Phlebography of recurrent varicose veins provides useful information supplementary to that furnished from clinical examination alone.

Recurrence following Varicose Vein Surgery

Objective:

To determine the site-specific rates of recurrence following varicose vein surgery.

Design:

Postal questionnaire followed up by telephone enquiries. Full clinical review, including continuous wave and duplex Doppler investigations were carried out for all patients with responses suggesting recurrence.

Setting:

Surgicare Manchester, an independent provider of specialist varicose vein treatments. All procedures were guided by Doppler ultrasound and performed by surgeons working to the same protocol.

Subjects:

A consecutive series of 250 operations on 246 Patients. Of these, 208 (85%) could be contacted for follow-up. Mean time to re-examination was 27 months.

Results:

Twelve patients returned spontaneously and 51 were recalled for examination based on questionnaire responses. Recurrences were divided into ‘site’, ‘perforator’ or ‘new site’ recurrence. Primary surgery to the sapheno-femoral junction (SFJ) had the lowest ‘site’ recurrence rate of 2.3% compared with 9.5% for SFJ re-operation. Primary surgery and re-operation of the sapheno-popliteal junction (SPJ) had higher recurrence rates of 8.3% and 7.8% respectively. New incompetence was detected in 5% and 2% of previously competent SFJ and SPJ respectively. Minor perforator incompetence was found in a further 14%.

Conclusions:

Varicose veins were progressive in some individuals, with new sites of incompetence appearing over time. However, ‘cure’ remains possible for most Patients and major recurrence can be reduced by Doppler diagnosis and precise surgery.

Neovascularization in Recurrent Sapheno-Femoral Incompetence of Varicose Veins: Surgical Anatomy and Morphology

Objective:

To investigate the surgical anatomy and morphology of recurrent sapheno-femoral incompetence after correctly performed sapheno-femoral ligation. To test the hypothesis that such recurrence develops through neovascularization.

Design:

Prospective study of single patient group.

Setting:

Varicose vein clinic of teaching hospital.

Patients:

One hundred and twenty-eight patients (141 limbs) were reviewed 4 or more years after accurately performed sapheno-femoral ligation with catgut, silk or tantalum wire.

Intervention:

Clinical assessment, phlebography, surgical exploration and examination of recurrent veins by radiographic and histological methods.

Main outcome measures:

Presence of reflux through newly formed veins at the site of previous ligation.

Results:

Of 141 limbs, clinical or phlebographic evidence of sapheno-femoral recurrence was confirmed in 35 of 37 on surgical exploration. The continuity of the saphenous vein with the previously ligated sapheno-femoral junction was restored through a newly formed vein or complex of veins.

Conclusions:

Neovascularization was the cause of recurrent sapheno-femoral incompetence after correctly performed sapheno-femoral ligation.

Duplex Ultrasound Scanning for Chronic Venous Disease: Recurrent Varicose Veins in the Thigh after Surgery to the Long Saphenous Vein

Objective:

To use duplex ultrasound scanning to compare limbs with recurrent and primary varicose veins and to identify connections between deep veins and recurrences.

Setting:

A non-invasive vascular laboratory in Melbourne, Australia.

Patients:

A study of 779 limbs with recurrent varicose veins previously treated by ligation or stripping of the long saphenous vein and 1521 limbs with primary varicose veins.

Main outcome measures:

Connections between deep veins and recurrent varices, reflux in superficial and deep veins, and outward flow in perforators as demonstrated by duplex ultrasonography.

Results:

Recurrence was due to reflux in the long saphenous territory in 71.8%, short saphenous reflux alone in 14.7% or outward flow in calf perforators without saphenous reflux in 5.2%, while no source was detected in 8.3%. Limbs with recurrent veins in the long saphenous territory were compared with limbs with primary varicose veins; there was more frequent outward flow in thigh perforators (25.2% vs. 16.2%) but no difference for deep reflux (20.7% vs. 17.5%) or outward flow in calf perforators (56.8% vs. 53.1%). The source for recurrence in the long saphenous territory was from a single large connection in the groin in 46.3%, multiple smaller proximal connections in a further 46.3%, or thigh perforators in 7.4%. The destination was to an intact long saphenous vein in 33.7%, major tributaries in 28.7% or to other varices in 37.6%. Limbs known to have been treated by long saphenous ligation alone were compared with those known to be treated by long saphenous ligation and stripping; the source was more likely to be from a single large vein in the groin (60.3% vs. 39.9%) and the destination was more likely to be an intact long saphenous vein or major tributary (75.0% vs. 55.2%).

Conclusions:

Duplex ultrasound scanning detected the source of recurrent varicose veins in over 90% of patients and demonstrated whether there were single large or multiple smaller connections in the veins affected, and this helps to select the most appropriate treatment. Recurrence after stripping the long saphenous vein was more likely to be due to multiple small connections passing to scattered varices and this may allow more simple treatment by injection sclerotherapy rather than repeat surgery.

Assessment and Treatment of Varicose Veins in the Northern Region

Objective:

To identify the current practice of surgeons and variations between these surgeons in the investigation and treatment of varicose veins.

Design:

Questionnaire submitted to all surgeons treating varicose veins.

Setting:

All general surgeons in the Northern Region of England.

Results:

The response was 83% with 60 surgeons (85% of responders) treating varicose veins. Thirty-five per cent have a vascular specialist interest and treat 58% of all the varicose veins; 37% of surgeons complement initial assessment by clinical examination with hand-held Doppler examination. For long saphenous vein incompetence all surgeons perform high saphenous ligation, with 67% stripping the vein to the knee and 23% to the ankle. For short saphenous incompetence, 28% localize the saphenopopliteal junction by investigation prior to treatment, 92% perform saphenopopliteal ligation and 13% strip the vein.

Conclusions:

The extent of investigation and the nature of treatment of varicose veins vary considerably between consultants. Relatively few surgeons use hand-held Doppler and surgeons remain divided on the use and extent of stripping of the saphenous veins.

Neovascularisation is not an innocent bystander in recurrence after great saphenous vein surgery

INTRODUCTION

This study sought to establish the causes of failure of great saphenous vein surgery among patients in whom there was confidence that accurate saphenofemoral ligation had been carried and the great saphenous vein had been stripped at least to knee level.

METHODS

This was an observational study of 100 limbs (66 patients) operated on by a single surgeon 5-22 years previously (mean: 12 years). The index operation was primary in 54 limbs and for recurrence in 46 limbs. Thirty-two patients were studied having been re-referred for recurrence while 34 were recalled for review. All were examined clinically and with duplex ultrasonography, and all completed questionnaires (Aberdeen varicose vein questionnaire [AVVQ] and EQ-5D-3L). In order to measure the extent of visible recurrence, a scoring system similar to that in the venous clinical severity score was used but with a range of 0-8.

RESULTS

There were visible varicosities in 77 of the 100 limbs. Duplex ultrasonography showed that recurrent saphenofemoral incompetence (SFI) was present in 27% of the limbs. This was judged to result from neovascularisation and was the most common source of reflux. AVVQ scores for the 27 limbs with recurrent SFI (median: 34, interquartile range [IQR]: 20-42) were higher than for the 73 with no recurrent SFI (median: 17, IQR: 11-29), which was a significant difference (Mann-Whitney U test, p<0.01). Analysing clinical scores with chi-squared tests indicated fewer visible varicosities in limbs without recurrent SFI than in those with recurrent SFI (p<0.01).

CONCLUSIONS

Neovascularisation remains poorly understood but it cannot be considered an innocent bystander.

Long-term results of vein sparing varicose vein surgery

The aim of this study was to assess the long-term functional outcome of vein sparing varicose vein surgery using handheld Doppler ultrasound (HHD). The series consisted of 171 consecutive day-case surgery patients operated on for uncomplicated lower limb varicose veins. Venous segments considered competent were spared based on clinical examination and HHD, which was performed preoperatively only when deemed necessary by the surgeon. After a mean follow-up of 8 years all patients were examined, a systematic HHD evaluation was performed, and the findings were classified according to the CEAP (Clinical, Etiological, Anatomical, Pathophysiological) classification, and disability scoring was performed. During the follow-up period 17% of the legs were reoperated or scheduled for reoperation. At follow-up 79% of all patients were asymptomatic without reoperation. In 24%, recurrent varicosities were present and venous reflux was demonstrated by HHD. Recurrence was two times more common when the saphenofemoral junction had originally been left intact. Of all recurrent cases, reflux was demonstrated in the long saphenous vein (LSV) above the knee in 62%, in the LSV below the knee in 7%, in the short saphenous vein (SSV) in 16%, in the posterior arch vein in 38%, and in a thigh perforator in 8%. Of the legs reoperated during the follow-up period 41% presented with venous reflux at the follow-up visit. We conclude that HHD efficiently reveals sites of reflux that have been missed during previous surgery and that a thorough preoperative HHD examination and marking of reflux routes is required.

Evaluation of the venous reflux of the great saphenous vein by duplex scan after surgical treatment of the saphenofemoral junction insufficiency

OBJECTIVE

To evaluate the occurrence of reflux from the great saphenous vein by color Doppler ultrasonography in subjects undergoing treatment of insufficiency of the saphenofemoral junction by simple ligation or ligation with section of the saphenous arch.

METHODS

We performed 60 operations (in 45 subjects) of varicose insufficiency of the saphenofemoral junction (SFJ), belonging to the CEAP clinical classification of 2-5, who were randomly divided into two groups. A group called C, with ligature and section of the saphenous arch, and a group called L, with simple ligation of the saphenous vein and no sectioning of its arch. We then investigated the occurrence of reflux from the great saphenous vein in groups C and L through postoperative color Doppler ultrasonography at intervals of six months to one year.

RESULTS

Of the 60 members submitted to the approach of the saphenous arch, 57 were evaluated by postoperative doppler ultrasound, since two subjects (three limbs) did not return and were excluded from the study. The mean age was 54 years, with 93% females and predominance of CEAP classification 2 in 60.5%. Of the 57 operations for the treatment of reflux of the saphenous arch, 43.9% had reflux postoperatively,14.1% in group C and 29.8% in group L (p < 0,05). The relative risk of reflux of the saphenous arch in group L was 2.03 times higher compared with group C.

CONCLUSION

the section of the arch of the great saphenous vein causes less postoperative reflux than simple ligation in treatment of insufficiency of the great saphenous vein.

Day-case re-do varicose vein surgery

OBJECTIVE

To assess whether re-do varicose vein surgery as a day case is feasible and safe.

METHODS

Data were collected retrospectively on 70 consecutive patients (77 legs) undergoing re-do sapheno-femoral or sapheno-popliteal ligation by consultant surgeons as day cases. Follow-up was by structured telephone interview.

RESULTS

The 70 patients comprised 53 females and 17 males. Median age and body mass index were 47.5 years and 27, respectively. All patients were ASA Grade I or II. Median operating time was 75 min (range 25-140). Of the 70 patients intended to be treated as day cases, four (5.7%) were admitted overnight. There were no were re-admissions nor did any patient develop deep vein thrombosis. Eleven per cent developed wound infection and 4% transient lymphatic leakage. Overall, 91% of patients were pleased with the initial surgical result but this decreased to 81% in the longer term. Eighty-nine per cent would have their surgery performed again as a day case.

CONCLUSION

Re-do sapheno-femoral or sapheno-popliteal can be performed safely as a day case.

Estudo comparativo entre os achados do exame físico, do mapeamento com eco-color Doppler e da exploração cirúrgica na recidiva das varizes de membros inferiores a partir da junção safeno-femoral

CONTEXTO: A recidiva de varizes em membros inferiores é complicação frequente da safenectomia e sua incidência atinge até 80% dos casos. OBJETIVO: Avaliar a sensibilidade do exame físico e do mapeamento com eco-color Doppler no diagnóstico da insuficiência do coto da veia safena magna, em doentes previamente operados, comparando-os com os achados da exploração operatória da junção safeno-femoral. MÉTODOS: Foram estudados prospectivamente 30 doentes envolvendo 37 membros submetidos previamente à safenectomia magna para tratamento de varizes e que foram reoperados por recidiva de varizes na região inguinal ou em face anterossuperior da coxa. Todos os doentes foram submetidos ao mapeamento com eco-color Doppler. Os dados foram comparados com os achados da exploração da crossa da veia safena magna na reoperação. RESULTADOS: A sensibilidade do mapeamento com eco-color Doppler para a presença de insuficiência do coto da veia safena magna foi de 70,3% (26 concordâncias dentre os 37 membros) e resultados falsos negativos ocorreram em 29,7% (11) membros avaliados (p=0,03). A sensibilidade do achado de varizes na região inguinal e na face anteromedial da coxa com a presença de insuficiência do coto da veia safena magna foi de 100% (37 concordâncias dentre os 37 membros) e não houve resultados falsos negativos. CONCLUSÕES: No doente já submetido à safenectomia magna, a presença no exame físico de varizes recidivadas em região inguinal e na face anteromedial da coxa é sugestivo de insuficiência do coto da veia safena magna, devendo-se realizar o mapeamento com eco color Doppler para o adequado planejamento da reexploração da crossa da veia safena magna.

Endovenous laser ablation as a treatment for postsurgical recurrent saphenous insufficiency

The purpose of this study was to investigate the safety and efficacy of endovenous laser ablation as a treatment for recurrent symptomatic saphenous insufficiency occurring after saphenous vein ligation and stripping. A single-center retrospective review of patients who received endovenous laser ablation as a treatment for recurrent symptomatic saphenous insufficiency after ligation and stripping between November 2003 and October 2006 was performed. Fifty-six insufficient saphenous systems were identified in 38 patients. Follow-up consisted of a clinical examination in all patients as well as selective lower-extremity duplex ultrasound as clinically indicated. All 38 patients demonstrated complete closure of the insufficient saphenous vein by clinical examination and/or duplex ultrasound evaluation. Preoperative symptoms resolved after treatment in all 38 patients. No major complications were identified. Endovenous laser ablation of recurrent symptomatic saphenous venous insufficiency is a safe and effective treatment in patients who develop recurrent symptoms after saphenous vein ligation and stripping.

An overview of the surgical aspects of lower limb venous disease

Lower limb venous disease encompasses a wide spectrum of pathology, the importance of which relates to high prevalence rather than mortality. The complications of chronic venous insufficiency (CVI), namely lipodermatosclerosis and chronic venous ulceration, represent a major burden to healthcare providers and a high degree of personal morbidity for patients. Management is based upon accurate clinical diagnosis supported by non-invasive imaging. Open surgical and minimally invasive techniques are used to treat varicose veins. Chronic skin complications of CVI require a multidisciplinary approach.

[Phlebectomies or foam sclerosis for treatment of the distal venous segment in the 3-S saphenectomy technique]

INTRODUCTION

The aim of this study was to compare the recurrent rates of varicose veins after treatment with two surgical techniques: 3-S saphenectomy and 3-S saphenectomy with distal sclerosis.

PATIENTS AND METHOD

105 patients with trunk varicose veins were randomly assigned. The control group consisted of 51 patients who underwent the 3-S saphenectomy technique (the sapheno-femoral junction sclerosis with foam, saphenectomy and distal phlebectomies); test group: 3-S saphenectomy with distal sclerosis technique (the sapheno-femoral junction sclerosis with foam, saphenectomy and distal segment sclerosis).

RESULTS

Overall recurrence: group I 35.3%, group II 57.4% (p < 0.001). Trunk recurrence: group I 17.7%, group II 38.9% (p = 0.028). Collateral recurrence: group I 9.8%, group II 11.1% (p = 1). Perforator vein recurrence: group I 5.9%, group II 5.6% (p = 1). Reticulated recurrence: group I 2%, group II 1.9% (p = 1).

CONCLUSIONS

The substitution of Müller phlebectomy instead of foam sclerosis, is not a better treatment of the distal venous segment, and has a greater recurrence rate. The 3-S saphenectomy technique is the most suitable for the treatment for trunk varicose veins.

Results and significance of colour duplex assessment of the deep venous system in recurrent varicose veins

OBJECTIVES

To establish the status of the deep veins in patients presenting with recurrent varicose veins and the effect on treatment decisions.

DESIGN

Retrospective clinical series.

MATERIALS AND METHODS

Duplex examination of 570 consecutive patients (843 limbs) presenting with recurrent varicose veins (CEAP C2-4).

RESULTS

Approximately one third of these patients (34.8%:294 limbs) had no deep venous abnormality; 173 limbs with superficial vein abnormalities only had great and/or small saphenous junction incompetence, the remaining 121 legs had abnormal perforating or communicating veins. Deep venous abnormalities were found in 549 limbs with evidence of persisting deep venous obstruction in only 20. Deep venous incompetence was found in 529 limbs (62.7% of all legs). However three segment incompetence (common femoral, femoral and popliteal veins) was found in only 181 legs (21.4%), two segment incompetence in 137 (16.2%) and one segment incompetence in 211 (25%).

CONCLUSIONS

Deep vein incompetence is common in patients with recurrent varicose veins. Deep venous obstruction is an infrequent finding but total deep venous reflux (three segment incompetence) affects just under one quarter of all limbs with recurrent varicose veins. Ablation or surgery of varicose veins in this group may be less effective. Patients should be advised of the implications of this finding.

Avaliação da bomba muscular da panturrilha em pacientes portadores de varizes primárias dos membros inferiores através da pletismografia a ar

OBJETIVO:Avaliar a influência do refluxo das veias musculares da panturrilha (surais e geniculares) na função da bomba muscular da panturrilha em pacientes com varizes primárias nos membros inferiores. MÉTODOS: Estudo transversal prospectivo, no qual os pacientes foram avaliados por meio de exame físico, mapeamento dúplexe pletismografia a ar. Foram selecionados 120 pacientes divididos em dois grupos (60 indivíduos em cada). O primeiro grupo apresentava refluxo das veias musculares da panturrilha e o segundo grupo apresentava ausência de refluxo. Cada grupo foi analisado com pletismografia a ar para estudo da função da bomba da panturrilha. As variáveis estudadas foram fração de ejeção, fração do volume residual, volume ejetado e índice de enchimento venoso para membro inferior direito e esquerdo. RESULTADOS: No grupo com refluxo, índices de fração de ejeção abaixo de 60% (com p < 0,001) foram encontrados em 82,3% (em perna esquerda) e em 74,6% (em perna direita) dos casos. Índices de fração do volume residual acima de 60% foram identificados em 62,5% (em perna esquerda, p = 0,015) e em 86,7% (em perna direita, p = 0,014) dos casos avaliados. Não houve variação estatisticamente significativa para o índice de enchimento venoso entre os grupos com e sem refluxo, com p = 0,140 e p = 0,140 para pernas esquerda e direita, respectivamente. Foram encontrados 63,6% dos pacientes com refluxo das veias da panturrilha (em perna esquerda), e 61,8% (em perna direita) com volume ejetado acima de 150 mL (p = 0,001). CONCLUSÕES: Houve alteração da bomba muscular da panturrilha, levando a uma diminuição de sua função, em ambos os membros inferiores por conseqüência da presença do refluxo das veias musculares da panturrilha (geniculares e surais).

Recurrent varicose veins following surgical treatment: our experience with five years follow-up

OBJECTIVE

To report the 5 year outcome of varicose veins surgery and to establish the factors determining recurrence.

STUDY DESIGN

Prospective observational study.

MATERIALS AND METHODS

This study reports the outcome in 1326 patients treated in a day surgery centre of an institutional referral centre. Patients were investigated clinically and by colour flow duplex scanning before operation. Treatments used included flush ligation of the sapheno-femoral junction (SFJ) and the sapheno-popliteal junction (SPJ). Incompetence of the great saphenous vein (GSV) and small saphenous vein (SSV) were managed by stripping of these veins. Perforating vein ligation and hook phlebectomy were also used. Patients were evaluated 3 weeks and 5 years following treatment by clinical examination and duplex ultrasonography.

RESULTS

412 patients were excluded from the study because they failed to attend for follow-up or did not wear elastic stockings post-operatively. No residual saphenous truncal reflux was found at the initial assessment 3 weeks following surgery. After 5 years, recurrence of varicose veins occurred in 332 patients out of 1326 (25 %). Recurrences arose at the sapheno-femoral junction in 109 out of 862 patients (13%), at the sapheno-popliteal junction in 39 out of 132 patients (30%), in both saphenous regions 38 out of 107 patients (36%) and in 146 out of 225 subjects (65 %) with secondary varicose veins.

CONCLUSION

Varicose veins recurred despite technically correct surgery confirmed on post-operative duplex ultrasonography. The likelihood of recurrence increased in the presence of SSV reflux, perforating vein incompetence and post-thrombotic deep vein incompetence.

Neovascularization: an "innocent bystander" in recurrent varicose veins

OBJECTIVE

Varicose vein recurrence after surgery occurs in up to 60% of patients. A variety of technical factors have been implicated, but biological factors such as neovascularization have more recently been proposed. The objective of this study was to characterize the relative contribution of technical and biological factors to recurrence in a large prospective series of recurrent varicose veins.

METHODS

Duplex and operative findings were recorded prospectively in a consecutive series of 500 limbs undergoing surgery for recurrent varicose veins between 1995 and 2005 in a university teaching hospital. Only limbs with previous saphenofemoral junction surgery were included. All limbs had preoperative duplex mapping by an accredited vascular technician who assessed the status of the great saphenous vein (GSV) in the thigh and groin, sought sonographic evidence of neovascularization, and reported on the presence of reflux in the short saphenous vein and perforator sites (typical and atypical). All operations were performed with an attending vascular surgeon as the lead operator.

RESULTS

Primary GSV surgery was incomplete in 83.2% of limbs. A completely intact GSV system was present in 17.4% of limbs. An incompetent thigh saphenous vein was present in 44.2% of limbs, 37.6% had GSV stump incompetence with one or more intact tributaries, and 16% had both a residual thigh GSV and an incompetent stump with intact tributaries. Non-GSV sites of reflux were identified in 25% of limbs. Neovascularization was identified on duplex scanning in 41 (8.2%) limbs. However, in 27 of these, surgical exploration revealed a residual GSV stump with 1 or more significant tributaries. Each of the remaining 14 (2.8%) limbs had a residual incompetent thigh GSV.

CONCLUSIONS

Despite reports to the contrary, neovascularization occurs in a relatively small proportion of patients with recurrent varicose veins. All recurrent varicose veins associated with duplex-diagnosed neovascularization are also associated with persistent reflux in the GSV stump tributaries, thigh GSV, or both. Recurrence after primary varicose vein surgery is associated with inadequate primary surgery or progression of disease, and neovascularization alone is not a cause of recurrent varicose veins.

Stripping and ligation of the saphenous vein

Successful varicose vein surgery depends on accurate preoperative assessment and individualized treatment for various combinations of venous insufficiency. Noninvasive duplex scanning is currently the gold standard in varicose vein evaluation. Flush ligation and division of the great saphenous vein and its tributaries, inverted downward stripping to below the knee combined with stab avulsion of varicosities, have yielded excellent results for patients with great saphenous vein reflux. Additionally, identifying and correcting incompetent calf perforating veins is necessary to achieve a satisfactory outcome. Neovascularization at the saphenofemoral junction and varicose vein recurrence and their treatment remain unsolved and require further investigation.

Management of the Primary Varicose Veins With Venous Ulceration With Assistance of Endoscopic Surgery

Two hundred sixty-two cases of primary varicose veins in which the lesions extended to the areas of the lower third of the leg and/or the ankle were treated with the assistance of endoscopic surgery. The conditions of varicose veins were classified by the reporting standards in venous disease. The number of cases in lesions of C2, C4, C5, and C6 were 60, 156, 31, and 15, respectively. They were also classified into 4 clinicoanatomic types according to varicositic changes in normal veins. The number of cases in types I, II, III, and IV were 57, 88, 42, and 75, respectively. The incidence of skin changes resulting from varicosity were 100%, 90.5%, 53%, and 50% in types I, II, III, and IV, respectively. The incidence of skin changes in this series was 77.6%. About one fourth of the cases having skin changes progressed to C5 and/or C6 lesions. Early and radical treatment of varicose veins could prevent the occurrence of skin changes and subsequently avoid the incidence of C5 and/or C6 lesions. The mean number of incisions in each limb was 2.9. With good illumination and magnified monitor view, the varicose veins and incompetent perforating veins were radically excised, but the normal veins were preserved. Forty-six cases of C5 and C6 lesions were followed up at least 1 year postoperatively. Four cases were lost from follow-up. In all cases except 1, there has been no recurrence. The conditions of skin changes improved subsequently. The recurrent rate of ulceration was 2.4%. In treatment of primary varicose veins with or without ulceration, surgery with assistance of endoscopic surgery achieved a low recurrence of ulcerations and minimal operative scarring.

Prevalência do refluxo na veia safena parva em varizes primárias não complicadas dos membros inferiores pelo eco-Doppler colorido

OBJETIVO: Determinar a prevalência de refluxo venoso na veia safena parva em membros inferiores com varizes primárias não complicadas pelo eco-Doppler colorido. MÉTODO: No período de 18 meses, 1.953 pacientes foram submetidos ao eco-Doppler colorido de membros inferiores por doença venosa. Destes, 1.631 com varizes primárias não complicadas foram selecionados para esta análise, sendo que 1.383 eram do sexo feminino (84,79%) e 248 (15,21%) do sexo masculino. A média de idade dos pacientes foi de 42,89 (± 0,48) anos, variando de 13 a 85 anos. Dos 1.631 pacientes, 1.323 foram submetidos a exame bilateral e 308 a exame unilateral, totalizando 2.954 membros inferiores com varizes primárias não complicadas avaliados. Desse total, 1.461 eram membros inferiores direitos e 1.493, esquerdos. Todos os exames foram realizados seguindo o mesmo protocolo. RESULTADO: Dos 2.954 membros inferiores avaliados, 372 (12,59%) apresentaram refluxo em veia safena parva. A prevalência nos homens foi de 14,08% e, nas mulheres, de 12,35%. O refluxo da safena parva foi maior no membro inferior esquerdo (13.13%) do que no direito (12,05%). A prevalência do refluxo foi significativamente maior nos pacientes acima de 60 anos. CONCLUSÃO: O refluxo da veia safena parva é relativamente comum, e sua pesquisa deve ser sempre realizada em pacientes com varizes primárias de membros inferiores.

Surgical treatment of varicose veins: effect of rationing

INTRODUCTION

A substantial part of vascular surgical workload is devoted to the treatment of varicose veins. To control demand for cosmetic venous surgery, primary care trusts in Somerset introduced clinical criteria in 2000 for the referral and treatment of varicose veins based on the presence of skin change or ulceration, a history of bleeding, or two or more episodes of thrombophlebitis.

PATIENTS AND METHODS

A comparison of workload and case mix for the referral and treatment of new patients presenting with varicose veins to the Taunton and Somerset Hospital was carried out over two 6-month periods, before and after the introduction of clinically based assessment criteria.

RESULTS

A total of 134 operations for varicose veins were carried out in 2000 and 85 such operations in 2002/03 after the introduction of new referral criteria (P = 0.001). Of these, 69% (92/134) were day-case procedures in 2000 compared to only 48% (41/85) in 2002/03 (P = 0.004). There was no significant difference in the type of cases (e.g. single, bilateral or recurrent surgery) performed as a day-case (P = 0.34) or as an in-patient (P = 0.43) over the two periods. There was, however, a significant difference (P = 0.007) in the mean ages of patients in the two periods (48.5 years in period 1; 57.8 years in period 2) and in the average ASA grade (1.15 in period 1; 1.42 in period 2; P = 0.0002).

CONCLUSION

The introduction of clinical criteria for the referral and treatment of varicose veins reduced workload by 37%.

Patient characteristics and physician-determined variables affecting saphenofemoral reflux recurrence after ligation and stripping of the great saphenous vein

OBJECTIVE

To identify patient and physician-controlled treatment variables that might predict the persistence or redevelopment of saphenofemoral junction (SFJ) reflux.

METHODS

Thirteen European centers, with substantial lower extremity venous disease practices, examined their experience with SFJ ligation and GSV stripping for primary varicose veins in patients followed for > or =2 years, entering their data into a protocol-driven matrix that stipulated duplex Doppler imaging as an essential component of follow-up examinations and required a complete review of all peri-operative examinations, as well as all operative procedure and anesthesia notes. Matrix entries were centrally audited for consistency and credibility, and queried for correction or clarification before being accepted into the study database. Presence or absence of Doppler-detectable SFJ reflux was the dependent variable and principal outcome measure.

RESULTS

Among 1,638 limbs, 315 (19.2%) had SFJ reflux. After adjustment for follow-up length and inputting for missing values, multivariable analysis identified seven significant predictors. Ultrasonic groin mapping (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.20 to 0.40) and <3-cm groin incisions at or immediately below the groin crease (OR, 0.50; 95% CI, 0.32 to 0.78) were both uniquely associated with diminished probability of follow-up SFJ reflux. Prior parity (OR, 2.69; 95% CI, 1.45 to 4.97), body mass index >29 kg/m(2) (OR, 1.65; 95% CI, 1.12 to 2.43), <3-cm suprainguinal incisions (OR, 3.71; 95% CI, 1.70 to 5.88), stripping to the ankle (OR, 2.43; 95% CI, 1.71 to 3.46), and interim pregnancy during follow-up (OR, 4.74; 95% CI, 2.47 to 9.12), were each independent predictors of a greater probability of having SFJ reflux.

CONCLUSIONS

The findings suggest that ultrasound groin mapping, reticence for short suprainguinal or longer groin incisions and extended stripping, and counseling women about the effect of future pregnancy are prudent clinical choices, especially for obese or previously parous patients.

The Clinical Effectiveness of Hand Held Doppler Examination for Diagnosis of Reflux in Patients with Varicose Veins

OBJECTIVE

To assess the accuracy of hand held Doppler (HHD) as a rapid screening test for selecting varicose vein patients for duplex imaging.

DESIGN

Prospective single blind study of consecutive patients in a randomised trial.

MATERIALS

Use of hand held Doppler and duplex ultrasound scanners.

METHODS

One thousand two hundred and eighteen legs (943 patients) were examined by HHD and then duplex. HHD examiners recorded whether they would normally have requested duplex.

RESULTS

HHD results of one Clinical Assistant (166 limbs) were significantly poorer than all others and his results were excluded from analysis. Duplex would not have been requested in 645 of 1052 (62%) limbs. Among these HHD missed significant reflux in the long saphenous vein in 18 (3%) and the short saphenous in 25 (4%). Reasons for requesting duplex were popliteal fossa reflux (202); recurrent (94) or atypical (86) varicose veins; and possible previous thrombosis (67). Differences were observed between staff and units in requests for duplex; and in thoroughness and style of duplex reporting.

CONCLUSIONS

Selective use of HHD can avoid duplex imaging for many patients, with a low failure rate for detecting correctable venous reflux. Observed variations between individuals and units in results of HHD and duplex imaging have implications for the increasing use of duplex by clinicians.

Anatomical variation at the saphenofemoral junction

Background

This study was designed to document the surgical anatomy of the saphenofemoral junction (SFJ).

Methods

The anatomy of the SFJ was recorded diagrammatically in 2089 consecutive groin dissections performed to treat primary varicose veins. The number of primary tributaries, bifid systems, junctional tributaries and the relationship of the external pudendal artery (EPA) to the long saphenous vein (LSV) were recorded.

Results

The LSV was bifid in 18·1 per cent of legs. The number of tributaries at the SFJ varied from one to ten. In 33·4 per cent one or more (junctional) tributaries joined the LSV or common femoral vein deep to the deep fascia. The EPA crossed anterior to 16·8 per cent of LSVs. In 4·6 per cent it passed posterior to one large tributary or trunk of a bifid LSV and anterior to the second trunk, making identification of the second trunk particularly difficult.

Conclusion

A thorough understanding of the anatomical variations of the SFJ is important in ensuring that the junction is managed safely and adequately in patients with varicose veins. Failure to appreciate these variations may account for a significant proportion of inadequate primary varicose vein surgery.

Saphenofemoral Venous Channels Associated with Recurrent Varicose Veins are not Neovascular

BACKGROUND

Recurrence of varicose veins after apparently adequate surgery is common. Neovascularisation, the formation of new vascular channels between a venous surgery site and new varicosities, is thought to be an important cause of recurrence. The aim of this study was to provide histological evidence of the 'neovascularisation'process.

METHOD

Tissue samples from the region of the previously ligated saphenofemoral junction (SFJ) were taken from 14 limbs with recurrent varicose veins and from nine control limbs. Tissue samples were analysed histologically for overall vascularity, and the presence of intimal circular fibrosis, intimal eccentric fibrosis, medial thickened elastosis, and thrombosis in the microscopic thin walled vessels within the tissue. The same samples were analysed immunohistoligically for S100, a neural marker, and Ki-67 (Mib 1), a marker of endothelial proliferation. Absent S100 and positive Ki-67 were considered as evidence of new vessels.

RESULT

No significant difference was found between the venous recurrence and control groups in respect to histological features. S100 positive nerve fibrils were seen associated with dilated venous channels in the majority of both redo and control groups (p=1, Fisher's exact test). Only one section stained positively with Ki-67 (Mib1) in a single vascular channel for a few endothelial cells. The remaining control and redo cases were negative for Mib 1 (p=1, Fisher's exact test).

CONCLUSION

We found little evidence of neovascularisation associated with recurrent varicose veins in the saphenofemoral region. The venous channels that develop at the previously ligated SFJ may represent adaptive dilatation of pre-existing venous channels (vascular remodelling), probably in response to abnormal haemodynamic forces.

Surgery versus sclerotherapy for the treatment of varicose veins

BACKGROUND

Varicose veins are a relatively common condition and account for around 54,000 in-patient hospital episodes per year. The two most common interventions for varicose veins are surgery and sclerotherapy. However, there is little comparative data regarding their effectiveness.

OBJECTIVES

To identify whether the use of surgery or sclerotherapy should be recommended for the management of primary varicose veins.

SEARCH STRATEGY

Thirteen electronic bibliographic databases were searched covering biomedical, science, social science, health economic and grey literature (including current research). In addition, the reference lists of relevant articles were checked and various health services research-related resources were consulted via the internet. These included health economics and HTA organisations, guideline producing agencies, generic research and trials registers, and specialist sites.

SELECTION CRITERIA

All studies that were described as randomised controlled trials comparing surgery with sclerotherapy for the treatment of primary varicose veins were identified.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted and summarised data from the eligible studies using a data extraction sheet for consistency. All studies were cross-checked independently by the reviewers.

MAIN RESULTS

A total of 2306 references were found from our searches, 61 of which were identified as potential trials comparing surgery and sclerotherapy. However, only nine randomised trials, described in a total of 14 separate papers, fulfilled the inclusion criteria. Fifty trials were excluded and one trial is ongoing and is due for completion in 2004. The trials used a variety of outcome measures and classification systems which made direct comparison between trials difficult. However, the trend was for sclerotherapy to be evaluated as significantly better than surgery at one year; after one year (sclerotherapy resulted in worse outcomes) the benefits with sclerotherapy were less, and by three to five years surgery had better outcomes. The data on cost-effectiveness was not adequately reported.

REVIEWERS' CONCLUSIONS

There was insufficient evidence to preferentially recommend the use of sclerotherapy or surgery. There needs to be more research that specifically examines both costs and outcomes for surgery and sclerotherapy.

Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography

OBJECTIVE

We observed long-term venous ultrasound and plethysmographic changes after varicose vein surgery, to determine factors that influence recurrence.

METHODS AND MATERIALS

This observational sequential prospective study was carried out in an institutional referral center with day surgery. Subjects were 92 consecutive patients, ages 20 to 75 years, with symptomatic varicose veins in 127 limbs, who were able to complete regular assessment. Superficial varicose vein surgery included significant perforator vessels only, defined at preoperative duplex ultrasound scanning and air plethysmography. Similar follow-up assessments were performed at 3 weeks, 3 months, and 1, 3, and 5 years.

RESULTS

At 3 weeks venous reflux but not muscle pump function was consistently improved in all limbs. However, inadequate surgery at the major junctions was clearly identified as contributing to recurrence of disease in 7.2% of limbs. Recurrence of varicose veins occurred in 1 of 100 limbs (1%) at the saphenofemoral junction and in 8 of 33 (25%) limbs at the saphenopopliteal junction. However, after 3 years disease recurrence at these sites had increased to 23% and 52%, respectively. Incompetent perforator vessels increased progressively in number. Clinical recurrence was 47.1%, and consistent with this was gradual deterioration in air plethysmographic measures of reflux, with physiologic recurrence (venous filling index, >2 mL/s) in 66% at 5 years. Late recurrence was predicted in limbs with multiple sites of reflux preoperatively, venous filling index greater than 2 mL/s, and some other persistent abnormality at duplex scanning at 3 weeks. There was no recurrence in 40 limbs in which these factors were normal at at 3 weeks. However, 29 of 53 limbs with normal venous filling index after operative intervention had deteriorated at 3 years.

CONCLUSION

Incomplete superficial surgery, in particular at the saphenofemoral and saphenopopliteal junctions, is a less frequent cause of recurrent disease, and neovascular reconnection and persistent abnormal venous function are the major contributors to disease recurrence.

Gross anatomy of primary varicose veins observed in endoscopic surgery

The gross anatomy of varicose veins is one of the most important factors in the study of varicosity. Because of wide variations in the extent of involvement and degree of severity of varicose veins, it is difficult to obtain live and intact specimens of varicose veins. With good illumination and magnified monitor viewing, the varicositic main channel, its tributaries, and the incompetent perforating veins can be dissected and visualized clearly during endoscopic surgery. Thus, the whole range of varicosities can be observed directly in situ. Characteristic features of the varicosities of 350 limbs have been recorded by video and photographs for study and classification. These features include: 1) poor contractility of varicose veins; 2) dilated and tortuous changes of varicose veins; 3) saccular or lateral bulging deformities of vein walls, or both; 4) uniformly dilated and tortuous deformities of a long vein; 5) varicositic changes of the accessory vein; 6) anatomic abnormalities of varicose veins, such as supernumerary tributaries, varicositic clusters, and a crowded relationship among the long saphenous vein, perforating vein and tributaries; 7) various conditions of the perforating veins; and 8) the close relationship among the long saphenous vein, perforating veins, and the saphenous nerve. These data provide valuable information for the study and management of primary varicose veins.

The effect of long saphenous vein stripping on quality of life

PURPOSE

Long saphenous vein (LSV) stripping in the treatment of varicose veins may reduce the recurrence of varices but may also increase morbidity rates. The effect of stripping on health-related quality of life (HRQoL) is unknown. The aim of this study was to examine the effect of LSV surgery, with and without successful stripping, on HRQoL.

METHODS

This prospective study comprises 102 consecutive patients who underwent varicose vein surgery that included attempted stripping of the LSV to the knee. HRQoL was assessed before surgery and at 4 weeks, 6 months, and 2 years after surgery with the Aberdeen varicose vein severity score (AVSS; disease-specific) and the Short-Form 36 (SF-36; generic). Patients defined as stripped were those in whom complete thigh stripping to the knee was confirmed with postoperative duplex scanning at 2 years. Patients defined as incompletely stripped were those in whom any LSV remnant was found in the thigh after surgery. Deep venous reflux (DVR) was defined as reflux of 0.5 seconds or more in at least the popliteal vein.

RESULTS

Sixty-six of 102 patients (65%) provided complete HRQoL data at all four time points. At baseline, there was no significant difference between patients who were stripped (n = 25) and incompletely stripped (n = 41) in terms of AVSS, SF-36, age, gender, DVR, or CEAP grade. Significantly more patients in the incompletely stripped group underwent surgery for recurrent disease (29/41, 71%, versus 8/25, 32%; P =.002, with chi(2) test). Both groups gained significant improvements in AVSS scores for as much as 2 years. After adjustment for recurrent disease, stripping conferred additional benefit in terms of AVSS at 6 months (median [interquartile range]) (9 [4 to 16] versus 15 [9 to 24]; P =.031) and 2 years (7 [2 to 10] versus 9 [5 to 15]; P =.014), which was statistically significant in patients without preoperative DVR but not significant in patients with preoperative DVR. SF-36 scores were not affected by stripping.

CONCLUSION

LSV surgery leads to a significant improvement in disease-specific HRQoL for as much as 2 years. In patients without DVR, stripping to the knee confers additional benefit.

The Saphenofemoral Valve: Gate Keeper Turned into Rear Guard

Objective:

Trendelenburg's theory was based on the concept of a descending valvular incompetence com mencing at the saphenofemoral junction (SFJ) with subsequent distal progression of reflux. The aim of this study was to evaluate the distribution of reflux in patients with superficial venous incompetence in order to assess validity of the above hypothesis.

Procedures:

The superficial and deep venous system of a consecutive series of 443 patients presenting with primary varicose veins was examined by one vascular technologist using colour flow ultrasonography.

Results:

Six hundred and eleven lower limbs in 443 patients were examined. The distribution of long saphenous vein (LSV) reflux was the following: Of the 611 limbs 454 showed LSV reflux, with 240 legs exhibiting total reflux (SFJ and LSV) and 214 legs exhibiting reflux in evolution (LSV reflux with competent saphenofemoral valve, isolated posterior arch reflux and lateral anterior thigh vein reflux with SFJ reflux).

Conclusion:

These results suggest that reflux starts distally and progresses proximally, thus throwing the Trendelenburg theory into dispute.

Preoperative Assessment of Primary Varicose Veins: a Duplex Study of Venous Incompetence

OBJECTIVES

we investigated the importance of preoperative duplex scanning in primary uncomplicated varicose vein surgery by evaluating the incidence of superficial venous imcompetence and significant anatomical variations that may be difficult to detect clinically and therefore might be expected to contribute to recurrence.

DESIGN

a retrospective study of a prospectively collected database.

MATERIALS

over 15 consecutive months, patients attending the non-invasive vascular laboratory for duplex scanning of their primary uncomplicated varicose veins were assessed.

METHODS

vascular laboratory case notes were assessed and incidence of superficial venous incompetence and any significant anatomical variations that would have been difficult to detect clinically +/-HHD were documented. Any correlation with clinical findings was also evaluated.

RESULTS

a total of 223 limbs (176 patients) were assessed. Sixty-seven limbs (30%) in fact had a competent sapheno-femoral junction. Sixty-one limbs (27%) had pure sapheno-femoral reflux and nil else. Fifty-three limbs (24%) had significant anatomical variations. Forty-two limbs (19%) had short saphenous vein incompetence, of which 67% were clinically unsuspected.

CONCLUSIONS

preoperative duplex scanning is indicated in all patients with uncomplicated primary varicose veins if appropriate venous surgery is contemplated. There are obvious resource and recurrence rate implications. Further evaluation in the form of randomised trials are required.

Investigation of Venous Disease

Aim:

To review the investigations which are performed in patients presenting with varicose veins prior to treatment.

Method:

A review of current literature in the field of the investigation of venous disease of the lower limb has been conducted using MedLine.

Synthesis:

Continuous wave (CW) Doppler is effective in detecting venous reflux in the sapheno-femoral junction and the long saphenous vein. In the popliteal fossa, for perforating veins and for the deep veins this technique has reduced accuracy. Duplex ultrasonography is widely used in the management of venous disease of the lower limb. This investigation provides reliable anatomical information but limited functional data about the veins. Phlebography and varicography are effective investigations but are being replaced by duplex ultrasonography. Plethysmographic tests assess venous function but are poor at anatomical identification of the problem. They may be used in the monitoring of venous function during treatment and in identifying the contribution of superficial venous reflux in patients with combined deep and superficial venous disease.

Conclusion:

Clinical examination is no longer sufficient to assess patients with venous disease of the lower limb prior to surgery. CW Doppler is the minimum investigation but duplex ultrasonography is the most effective non-invasive investigation. Plethysmographic tests have limited application in the management of varicose veins.

Patterns of Incompetence in Patients with Recurrent Varicose Veins: A Duplex Ultrasound Study

Objectives:

To identify the patterns of venous incompetence in patients with recurrent varicose veins using duplex ultrasound scanning.

Setting:

Oldchurch District General Hospital, Southeast England.

Patients and methods:

836 patients (581 women, median age 51 years (range 22–86 years) and 255 men, median age 53 years (range 23–28 years) referred to the vascular laboratory for the assessment of recurrent varicose veins. Duplex ultrasonography was undertaken by an experienced operator to evaluate the venous system in the lower limbs. A total of 1254 limbs with recurrent varicose veins were studied.

Results:

Recurrent reflux was found at the sapheno-femoral (SFJ) or saphenopopliteal junction (SPJ) in 43% of cases. The source of recurrent varices was an unoperated SFJ or SPJ in 386 (31%) limbs. Thigh perforators accounted for varices in 16% of limbs.

Conclusion:

Nearly half of recurrences were attributable to inadequate surgical treatment at the initial operation or possible angiogenesis. Nearly a third of recurrences originated at previously unoperated sites, confirming a need for objective venous assessment before recurrent varicose vein surgery.

Recurrent varicose veins of both lower limbs due to bilateral ovarian vein incompetence

A case of a 43-year-old female patient with mild pelvic pain and bilateral recurrent varicose veins due to incompetence of both ovarian veins is presented here. Ovarian vein incompetence was suspected from the presence of vulva varicosities and was confirmed by transvaginal ultrasound and descending ovarian venography. Treatment with transcatheter embolization of the ovarian veins was followed by local excision of the leg varices. Four years later, the patient remains asymptomatic and without any recurrence of varicose veins in both lower limbs.

Reoperation for recurrent saphenofemoral incompetence: a prospective randomised trial using a reflected flap of pectineus fascia

OBJECTIVE AND DESIGN

in 1978 Sheppard described using a flap of pectineus fascia in an attempt to reduce the further development of neovascularised veins at the saphenofemoral junction. The perceived benefits of this manoeuvre have not been tested by a prospective randomised trial.

MATERIALS AND METHODS

consecutive patients with symptomatic recurrent varicose veins referred to a single consultant were examined for evidence of further reflux from the saphenofemoral junction. This was subsequently confirmed in forty limbs (thirty-seven patients) by descending venography. All had features of a neovascularised segment. These patients were treated by complete exposure and ligation of the recurrences arising from the common femoral vein, with or without the placement of a flap of pectineus fascia (prospectively randomised). The patients were assessed a minimum of eighteen months later by both clinical examination and duplex ultrasound scanning.

RESULTS

six patients were lost to follow-up. This left seventeen limbs remaining in each half of the study. The characteristics in each group were broadly matched.

CONCLUSIONS

this study failed to demonstrate any apparent benefit from the application of a flap of pectineus fascia. Most patients showed evidence of re-recurrence arising from the common femoral vein.

Recurrent varicose veins: patterns of reflux and clinical severity

Duplex scanning was used to determine patterns of recurrent varicose veins in 264 limbs and to relate these to clinical factors. All limbs had previously undergone sapheno-femoral ligation in the groin. A recurrent sapheno-femoral junction was present in 172 (65.2%). Incompetence was found in long or short saphenous veins in 232 limbs (87.9%), perforators in 176 (66.7%), and deep veins in 156 (59.1%). Residual long saphenous veins were present in 43.4% and 73.6% of limbs that were with and without stripped long saphenous veins, respectively. An incompetent thigh perforator was present in 14.0% and 15.3% of these two groups, respectively. Multiple sites of incompetence were observed in the majority (75.4%). In general, no particular reflux pattern in the groin was related to an increased incidence of ulceration. However, ulceration was more frequent in limbs with deep reflux to knee or below-knee levels. None of those with isolated reflux in the groin that was unrelated to the common femoral vein had ulceration. The pattern of reflux was unrelated to striping or non-striping of the long saphenous veins and the time since initial surgery. A history of deep vein thrombosis was invariably associated with some degree of deep reflux. A system of recurrent patterns in the groin is described for the purpose of surgical audit. In 15.1%, recurrence was attributed with some confidence to inadequate surgery. These results indicate that the pattern of recurrence is highly variable and often with multiple sites of incompetence. In a few instances, the pattern of recurrence was associated with specific clinical factors. A full work-up including duplex scanning is recommended.

Preoperative duplex imaging is required before all operations for primary varicose veins

BACKGROUND

Physical examination is unreliable in the detection of sources of reflux in varicose veins. Hand-held Doppler (HHD) ultrasonography has been recommended as an accurate adjunct to physical examination. The aim of this study was to evaluate the accuracy of HHD imaging in comparison with duplex ultrasonography.

METHODS

Eighty-nine legs in 61 patients with primary varicose veins were examined with an HHD probe to detect reflux at the saphenofemoral junction (SFJ), the saphenopopliteal junction (SPJ) and in thigh perforators (TPs). Patients then underwent duplex imaging and the results of the tests were compared.

RESULTS

The sensitivity of the HHD technique was 73 per cent at the SFJ, 77 per cent at the SPJ and 51 per cent for TPs. In primary varicose veins the surgery planned using HHD imaging alone would have left residual sites of reflux in 24 per cent.

CONCLUSION

Examination with HHD ultrasonography is not sufficiently accurate to plan varicose vein surgery. Duplex imaging is recommended before all operations for primary varicose veins.

Duplex sonographic evaluation of the sapheno-femoral venous junction in patients with recurrent varicose veins after surgical treatment

PURPOSE

We used duplex sonography in patients with recurrent varicose veins after surgical treatment to detect any residual stump of the great saphenous vein at the sapheno-femoral venous junction, and we compared these sonographic findings with surgical findings as the "gold standard."

METHODS

We prospectively studied 65 patients (54 women and 11 men) who had recurrent varicose veins 1-30 years (mean, 11 years) after surgical exploration of the groin and ligature of the great saphenous vein at its junction with the femoral vein. Duplex scans were performed in all patients before surgical reexploration. Sonographic findings were compared with surgical findings.

RESULTS

Duplex scanning revealed a residual stump in 47 patients (72%) and no stump in 15 patients (23%). Thirty-five (74%) of the 47 cases with a residual stump had reflux on duplex scans, and the remaining 12 cases (26%) showed no reflux. Findings in all 62 of these cases were confirmed by surgery. In only 3 patients (5%) did duplex scans fail to show a residual stump when surgery revealed a small residual stump without reflux.

CONCLUSIONS

Duplex scanning is the noninvasive diagnostic technique of choice to detect any residual stump of the great saphenous vein and to diagnose valve failure at the sapheno-femoral venous junction in patients with recurrent varicose veins.

Variable venous anatomy of the popliteal fossa demonstrated by duplex scanning

BACKGROUND

Location of the sapheno-popliteal junction (SPJ) is highly variable and therefore often difficult to identify correctly at operation. The anatomy is often complicated by associated pathology in the popliteal fossa, which makes clinical examination unreliable.

OBJECTIVE

The purpose of our study was to quantify this variability and record other concomitant pathology in patients with sapheno-popliteal junction incompetence.

METHODS

We retrospectively reviewed duplex scans of 544 patients with 638 legs showing SPJ incompetence, from a total of approximately 4000 patients attending our laboratory between August 1993 and August 1995.

RESULTS

We found that 51% of sapheno-popliteal junctions were located within 2 cm above the popliteal skin crease and a further 36% within 4 cm, with the remaining situated anywhere between 4 and 10 cm above the popliteal skin crease. Additionally 18% of patients had either Giacomini or gastrocnemius vein incompetence in addition to SPJ incompetence, further complicating the clinical picture.

CONCLUSION

When SPJ incompetence is suspected, duplex scanning identifies the exact location of the junction and other associated pathology in the popliteal fossa, and allows the position of the junction to be marked on the leg preoperatively.

The use of routine duplex scanning in the assessment of varicose veins

BACKGROUND

Clinical assessment has been shown to compare poorly with results of hand-held Doppler examination or venography in the evaluation of varicose veins. Although the use of duplex scanning has been well described in the assessment of varicose veins, there are few data comparing clinical and Doppler assessment with results of duplex scans.

METHODS

A total of 188 patients were referred with varicose veins to a sole specialist vascular surgeon over a 1-year period. After clinical and Doppler assessment, all patients were referred for a duplex scan which was performed by a trained vascular technician. The results of the duplex scan were compared retrospectively with the clinical and Doppler findings.

RESULTS

A total of 315 legs were assessed over this period, with 38.7% having recurrent disease and 31.4% having trophic skin changes or ulceration. On duplex scanning, 198 legs (62.9%) had saphenofemoral junction incompetence, 61 legs (19.4%) had saphenopopliteal junction incompetence, 94 legs (29.8%) had perforator incompetence and 24 legs (7.6%) had deep venous incompetence. The respective sensitivity of clinical and Doppler assessment at these sites was 71.2, 36.1, 43.6 and 29.2%. If patients who were felt to have sole saphenofemoral junction incompetence clinically were treated by high ligation, stripping to the knee and stab avulsions, 28.9% would have had sites of reflux untreated.

CONCLUSIONS

Clinical and Doppler assessment is unreliable. Routine duplex scanning is likely to reduce recurrence by identifying sites of reflux with greater accuracy.