Foot venous pressure measurement for evaluation of lower limb venous insufficiency

Acute effects of graduated and progressive compression stockings on leg vein cross-sectional area and viscoelasticity in patients with chronic venous disease

OBJECTIVE

To determine the effects of graduated and progressive elastic compression stockings (ECS) on postural diameter changes and viscoelasticity of leg veins in healthy controls and in limbs with chronic venous disease (CVD).

METHODS

In 57 patients whose legs presented with C_1S, C₃, or C₅ CEAP classes of CVD and treated primarily with compression, and 54 healthy controls matched for age and body mass index, we recorded interface pressures at 9 reference leg levels. Cross-sectional areas of the small saphenous vein (SSV) and a deep calf vein (DCV) were measured with B-mode ultrasound with subjects supine and standing, recording the force (PF) applied on the ultrasound probe to collapse each vein with progressive ECS, and with and without graduated 15‒20 mmHg and 20‒36 mmHg elastic stockings. We chose these veins because they were free of detectable lesion and could be investigated at the same level (mid-height of the calf), while their compression by the ultrasound probe was not hampered by bone structures.

RESULTS

Interface pressures decreased from ankle to knee with graduated 15‒20 and 20‒36 mmHg, but increased with progressive ECS, and were 8.4‒13.8 mmHg lower for C_1s than for control or C₃ and C₅ limbs. Without ECS, SSV median [lower‒upper quartile] cross-sectional area was 4.9[3.6‒7.1] and 7.1[3.0‒9.9]mm² in C₃ and C₅ limbs vs. 2.9[1.8‒5.2] and 3.8[2.1‒5.4]mm² in controls (p<.01), respectively while supine and standing. It remained greater in C₃ and C₅ than in C_1S and control limbs wearing any ESC. Wearing compression, especially with progressive ECS, decreased SSV and DCV cross-sectional area only with subjects supine, thus lowering postural changes which remained highly diverse between individuals. The SSV cross-sectional area vs. PF function traced a hysteresis loop of which the area, related to viscosity, was greater in C₃ and C₅ limbs than controls, even with graduated 15‒20 or 20‒36 mmHg ECS. Progressive ECS lowered vein viscosity in the supine position whereas 20‒36 mm Hg and progressive ECS increased distensibility in the standing position.

CONCLUSION

Elastic compression stockings reduce cross-sectional area of superficial and deep calf veins with patients supine but not upright. C_1s limbs show distinctive features, especially regarding interface pressures. Graduated 20‒36 mm Hg and progressive stockings lower viscosity and increase distensibility of the small saphenous vein.

A New Pragmatic Classification System for Varicose Veins

Objective:

An anatomical classification system for varicose veins which has a direct and pragmatic bearing on treatment.

Methods:

A group of trial participants from the two vascular units involved met to design a system. A consensus on the form and content of the system was reached. This process included forming a set of ideal classification criteria, a literature review of existing classification systems and a pilot study of the proposed system.

Results:

The identified classification systems were felt to be unsatisfactory for a number of reasons including being difficult to understand and use, requiring special investigations and not linking through to clinical management options. The pilot study demonstrated consensus between clinicians when using our system.

Conclusion:

A system has been developed that is easy to learn, use and understand. It can be employed in a busy outpatient setting and produces an acceptable degree of agreement regarding the anatomical nature of varicose veins.

Comparative study on the effectiveness of myofascial release manual therapy and physical therapy for venous insufficiency in postmenopausal women

OBJECTIVES

Venous insufficiency is present in a large number of postmenopausal women, increasing their risk of disability. The objective of this study was to determine the effects of myofascial release therapy and conventional kinesiotherapy on venous blood circulation, pain and quality of life in postmenopausal patients with venous insufficiency.

METHODS

A randomised controlled trial was undertaken. We enrolled 65 postmenopausal women with stage I or II venous insufficiency on the clinical, aetiological, anatomical and physiopathological (CEAP) scale of venous disorders, randomly assigning them to a control (n=32) or experimental (n=33) group. The control and experimental group patients underwent physical venous return therapy (kinesiotherapy) for a 10-week period, during which the experimental group patients also received 20 sessions of myofascial release therapy. Main outcome measures determined pre- and post-intervention were blood pressure, cell mass, intracellular water, basal metabolism, venous velocity, skin temperature, pain and quality of life.

RESULTS

Basal metabolism (P<0.047), intracellular water (P<0.041), diastolic blood pressure (P<0.046), venous blood flow velocity (P<0.048), pain (P<0.039) and emotional role (P<0.047) were significantly higher in the experimental group than in the control group after the 10-week treatment programme.

CONCLUSION

The combination of myofascial release therapy and kinesiotherapy improves the venous return blood flow, pain and quality of life in postmenopausal women with venous insufficiency.

Varicose veins: role of mechanotransduction of venous hypertension

Varicose veins affect approximately one-third of the adult population and result in significant psychological, physical, and financial burden. Nevertheless, the molecular pathogenesis of varicose vein formation remains unidentified. Venous hypertension exerted on veins of the lower extremity is considered the principal factor in varicose vein formation. The role of mechanotransduction of the high venous pressure in the pathogenesis of varicose vein formation has not been adequately investigated despite a good progress in understanding the mechanomolecular mechanisms involved in transduction of high blood pressure in the arterial wall. Understanding the nature of the mechanical forces, the mechanosensors and mechanotransducers in the vein wall, and the downstream signaling pathways will provide new molecular targets for the prevention and treatment of varicose veins. This paper summarized the current understanding of mechano-molecular pathways involved in transduction of hemodynamic forces induced by blood pressure and tries to relate this information to setting of venous hypertension in varicose veins.

Comparison of new continuous measurements of ambulatory venous pressure (AVP) with conventional tiptoe exercise ambulatory AVP in relation to the CEAP clinical classification of chronic venous disease

INTRODUCTION

Quantitative measurements of chronic venous insufficiency (CVI) are sensitive in detecting the presence of CVI but have low specificity in differentiating clinical severities of CVI as defined by the CEAP classification. One possible reason for this is measurement techniques do not assess variables that reflect hemodynamic changes that occur during normal exercise. Our aim was to compare the association of variables determined from a new technique, continuous ambulatory venous pressure monitoring (CAVPM), and those of conventional AVP measurement with the clinical severity of chronic venous insufficiency in patients with primary venous reflux.

METHODS

Fifty-four limbs of 49 patients with CVI and 15 healthy controls were studied. CVI clinical severity was classified according to CEAP as C2&C3 (mild disease), C4 (moderate disease), and C5&C6 (severe disease). All participants underwent duplex ultrasound scanning to rule out the presence of reflux in the control group and to confirm it in the patient groups. Conventional AVP measurements, including 90% refilling time (RT90), were compared with the new CAVP variables of mean walking pressure (MWP) and percentage fall in walking pressure (%FWP). Data were analyzed by analysis of variance using the Kruskal-Wallis test, and comparisons between groups were performed using Mann-Whitney tests. Discriminant analysis was used to determine the ability of a test to classify limbs into clinical classes.

RESULTS

Conventional AVP measurements could not differentiate between the control group and the presence of mild disease (P = .56) but did differentiate between controls and severe disease as well as mild and severe disease (P < .001). RT90 detected differences between controls and reflux groups (P < .001) but not between moderate (C4) and severe (C5&C6) clinical groups (P > .5). MWP and %FWP showed significant differences between all clinical severities and controls (P < .001).

CONCLUSION

In the assessment of CVI, mean walking pressure and percent fall in walking pressure are more reliably associated with anatomic distribution of reflux and clinical severity of CVI than the gold standard investigations of conventional AVP and RT90.

Microangiopathy of Split-Skin Grafts in Venous Ulcers

BACKGROUND

In patients with chronic venous insufficiency, microangiopathy of blood and lymph capillaries caused by venous hypertension plays a major role in the development of venous ulceration. Conservative treatment of venous leg ulcers often fails, and split-skin grafting is sometimes performed.

OBJECTIVE

To evaluate the microcirculation and especially the regeneration and function of lymphatic vessels in skin grafts in patients with chronic venous insufficiency.

METHODS

The microcirculation of 15 split-skin grafts was studied by fluorescence microlymphography and measurement of transcutaneous oxygen tension (tcpO2) in 13 patients.

RESULTS

The mean age of the skin grafts was 70.9 months. In only two skin grafts were a few intact lymph meshes found. In all other cases, only fragments of lymphatic capillaries have been detected. In seven skin grafts, cutaneous backflow of dye through insufficient deeper lymph channels was observed. The maximal spread of the dye in the lymphatic network was increased in the skin grafts (17.6 +/- 22.9 mm). The mean value of tcpO2 was only 27.1 +/- 18.1 mm Hg.

CONCLUSIONS

In split-skin grafts of patients with venous ulcers, severe microcirculatory changes are present and characterized by hypoxia and abnormal regeneration and function of lymphatic vessels.

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.

Prospective randomized blind controlled trial comparing sutures, tape, and octylcyanoacrylate tissue adhesive for skin closure after phlebectomy

BACKGROUND

The patient's view of the outcome after phlebectomy is mainly dependent on the cosmetic result.

OBJECTIVE

To compare 5-0 monofilament sutures with tapes and tissue adhesive for wound closure after varicose vein surgery.

METHODS

Seventy-nine patients undergoing varicose vein surgery were prospectively randomized in three groups (tissue adhesive, sutures, tape) for skin closure and compared. The follow-up 1 year postoperatively was done by a senior dermatologist who was blinded in the method of skin closure.

RESULTS

The cosmetic outcome showed little advantage for the suture group. Taping the incisions is faster than suturing them but without significance; closure with tissue adhesive takes nearly the double of time. The closure for one incision with tissue adhesive is 40 times more expensive than with tapes and 14 times more expensive than with sutures.

CONCLUSION

This study failed to demonstrate an advantage of tissue adhesive and tapes over monofilament sutures for skin closure after phlebectomy.

Assessment of lower extremity venous function using foot venous pressure measurement

BACKGROUND

Measurement of foot venous pressure (FVP) is useful for evaluating chronic venous insufficiency (CVI) functionally, because CVI always causes venous hypertension. In the present study, the various FVP parameters were analysed according to the new classification of venous disorders based on clinical, aetiological, anatomical and pathophysiological data (the CEAP classification).

METHODS

During the past 7 years, a total of 257 legs in 196 consecutive patients with CVI have been studied. The following FVP parameters were assessed: the percentage decrease in pressure from rest with manual calf compression, the rate of increase of pressure during 4 s after compression (4SR) and the time to 50 per cent recovery of pressure (RT50) after release of compression.

RESULTS

The incidence of skin changes due to venous stasis increased as the percentage pressure drop and RT50 fell. In addition, a pressure drop of less than 72 per cent and an RT50 of less than 20 s could detect legs with skin changes with a sensitivity of 76 per cent and a specificity of 62 per cent. In legs with primary varicose veins, pressure drop, 4SR and RT50 values deteriorated in proportion to the severity of the associated deep venous reflux.

CONCLUSION

FVP parameters correlate well with the severity of clinical manifestations and venous reflux, and could be used quantitatively to evaluate the severity of CVI.