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

Compression therapy versus surgery in the treatment of patients with varicose veins: A RCT

OBJECTIVE

Superficial venous reflux and varicose veins are common. The aim of this randomized controlled trial was to assess effectiveness of compression therapy compared with surgery for superficial venous reflux.

METHODS

153 patients with CEAP class C2-C3 and superficial venous reflux were randomized to receive either conservative treatment (compression stockings) (n = 77) or surgery (n = 76). Clinical examination including duplex ultrasound (DUS) was performed at entry and 1 and 2 years after randomization (compression group) or surgery (surgery group). Venous Clinical Severity Score without compression stockings (VCSS-S), Venous Segmental Disease Score (VSDS), Venous Disability Score (VDS), and health-related quality of life (HRQoL) were assessed at entry and at the follow-ups. Data were analysed on an intention-to-treat basis and according to the actual treatment performed.

RESULTS

At 2 years, 70/76 patients in the surgery group and 11/77 patients in the compression group had been operated on. VCSS-S decreased from 4.6 to 3.5 in the compression group (p < .01) and from 4.8 to 0.6 in the surgery group (p < .001). VSDS decreased from 7.7 to 7.0 in the compression group and from 8.2 to 0.9 in the surgery group (p < .0001). HRQoL did not change in the compression group, but improved significantly in the surgery group.

CONCLUSION

The surgical elimination of non-complicated superficial venous reflux is an effective treatment when compared with providing compression stockings only.

Analysis of a series of patients with varicose vein recurrence

OBJECTIVE

Varicose veins of the lower extremities is a common clinical condition. Although surgical treatment is often successful, the recurrence rate remains high. This retrospective study evaluated the reasons for postoperative recurrence of varicose veins by analysing ultrasonography and venography findings in patients with recurrent disease.

METHODS

A series of consecutive cases of recurrent varicose veins of the lower limbs was reviewed. Data collected included clinical characteristics, symptoms and vascular imaging.

RESULTS

The study included 109 legs with recurrent varicose veins (92 patients): 101/109 legs (92.7%) showed perforating vein insufficiency and 86/109 (78.9%) showed reflux of the superficial femoral vein, of varying degrees of severity. Residual saphenous vein was recorded for 82 legs (75.2%), while 19 (17.4%) had blocked iliac veins due to post-thrombotic syndrome.

CONCLUSIONS

Several factors that may contribute to varicose vein recurrence have been identified. These include failure to ligate perforating veins and initial failure to perform the appropriate surgical intervention. Prevention of varicose vein recurrence after surgical correction requires a more extensive use of preoperative imaging, to tailor surgical intervention to suit individual patients.

Standardisation of preoperative marking of incompetent perforators and saphenopopliteal junction on Doppler with evaluation of "t" technique

To standardise the preoperative marking of incompetent perforators and saphenopopliteal junction on Doppler with evaluation of "T" technique. A prospective study including 54 consecutive patients (61 lower limbs) who underwent surgery for varicose veins in 2003 and 2004 were included for preoperative marking. "T" technique is a technique of Doppler marking of an incompetent perforator, long limb of the T representing the course of the superficial vein and the junction of the T representing the site of perforator entering the deep fascia. Surgical correlation was done. The overall surgical detection rate of incompetent perforators was 199 / 220(90.5%); detection of the saphenopopliteal junction was 100%. The "T" technique of Doppler marking was found to be easy to perform and aided intraoperative detection.

Leg Ulcer Recurrence and its Risk Factors: A Duplex Ultrasound Study before and after Vein Surgery

OBJECTIVES

Assessment of risk factors for ulcer recurrence in chronic leg ulcer patients treated by varicose vein surgery.

DESIGN

Retrospective follow-up study.

MATERIALS

62 patients, 43 women and 19 men (Median=56.5 years, range 24-77) with the CEAP classifications of C(5)-C(6) and E(P) (primary venous insufficiency).

METHODS

Patients underwent colour duplex ultrasound (CDU) investigation before varicose vein surgery. Post-operatively CDU, ambulatory venous pressure (AVP) and an interview were performed. The median clinical follow-up was 5.5 years (range 2-11 years).

RESULTS

The estimated 5-year ulcer recurrence rate was 19% in all patients. The risk of ulcer recurrence was significantly lower (p<0.05) in legs without residual varices or recurrence. The five year risk of ulcer recurrence depended on the time interval between ulcer appearance and the surgical intervention (index operation), post-operative venous axial reflux and AVP (mmHg). More than 50% of the patients had a calculated probability of ulcer recurrence of less than 3%, but 13% had a probability of more than 23% based on our analysis.

CONCLUSIONS

A long history of venous ulcer is a pre- and post-operative risk factor for recurrent ulceration. Total elimination of incompetent superficial and perforator veins lowers the risk of ulcer recurrence, whereas residual axial reflux increases the risk. Postoperative CDU is effective in identifying patients at risk of ulcer recurrence.

A Colour Doppler Ultrasound Study of Venous Reflux in Patients with Chronic Leg Ulcers

OBJECTIVES

to evaluate the distribution of superficial and deep venous reflux in patients with chronic leg ulcers.

MATERIALS

retrospective study of 186 patients with chronic leg ulcers (212 lower limbs).

RESULTS

in 127 legs without arterial disease and a history of deep venous thrombosis (DVT), 62 (49%) had superficial, 45 (35%) had superficial and deep, and 14 (11%) had isolated deep venous reflux. In legs with a previous DVT, isolated deep venous reflux was more common (21/55, 38%) but superficial reflux, often in combination with deep reflux, still predominated (56%).

CONCLUSIONS

a large part of the venous insufficiency causing venous leg ulcers is superficial and suitable for varicose vein surgery. In patients with chronic leg ulcers most reflux affects the superficial system and is potentially suitable for surgical correction.

Patterns of reflux and severity of varicose veins in the general population--Edinburgh Vein Study

OBJECTIVES

several studies have used duplex ultrasound to assess valvular incompetence in symptomatic patients. This cross-sectional survey was performed to determine, for the first time in a general population sample, the relationship between trunk varices and the presence of reflux in lower limb venous segments.

MATERIALS AND METHODS

1238 subjects (554 male, 684 female), aged 18-64 years, were randomly selected. The presence and severity of any trunk varices was assessed and classified into Grades 1-3; hyphenweb and reticular varices were noted. The presence or absence of reflux > or = 0.5 s in five deep and three superficial venous segments in each leg was assessed using duplex ultrasound.

RESULTS

the prevalence of reflux increased in both superficial and deep segments with more severe grades of trunk varices (p< or = 0.01), except the upper SFV in women. Fifteen per cent of females showed reflux confined to the superficial system, compared with 9% of males (p< or = 0.001); 22% of males showed deep reflux, compared with 11% of females (p < or = 0.001). 71% of men and 48% of women with Grade 2-3 trunk varices had mixed deep and superficial reflux. Above-knee popliteal segments had a higher prevalence of reflux than lower SFV segments in all groups. There was no consistent relationship between the presence of hyphenweb or reticular varices and deep or superficial reflux.

CONCLUSION

segmental venous reflux can be detected in the deep and superficial leg veins of subjects without trunk varices, but superficial and mixed reflux are increasingly found in subjects with more severe varices.

Prevalence of deep venous anomalies in congenital vascular malformations of venous predominance

PURPOSE

The overall incidence of congenital vascular malformations in the general population is 1.5%. Approximately two thirds of them are malformations of venous predominance. Abnormalities of the deep venous trunks have been observed in association with large superficial compensatory varices in these type of malformations. Knowledge of the integrity of the deep venous system is important in their management because excision of the enlarged superficial veins may be deleterious if there is aplasia or hypoplasia of the deep venous trunks. The objective was to investigate the prevalence and nature of deep venous anomalies that occur in patients with congenital vascular malformations of venous predominance both in our series and in the series from the medical literature.

METHODS

From the last 35 years of medical literature, we reviewed seven series of congenital vascular malformations that provided pertinent information on the subject of our study. We also reviewed our own series of 392 patients with congenital vascular malformations studied at Children's Hospital of Mexico City (1963-1983; n = 223 children) and at Walter Reed Army and National Naval Medical Centers (1984-1998; n = 169 children). Of 392 patients, 257 (65.5%) had malformations of venous predominance; these were the subject of our analysis. Prevalence of the following deep venous anomalies was recorded: phlebectasia, aplasia or hypoplasia of venous trunks, aneurysms, and avalvulia. Diagnosis was made by one or more of the following methods: Doppler scanning, duplex scanning, plethysmography, computerized tomography, magnetic resonance imaging, and angiography.

RESULTS

At least one anomaly of the deep venous system was present in 47% of the congenital vascular malformations of venous predominance reviewed. Phlebectasia was recorded in 36% of the cases, and aplasia or hypoplasia of deep venous trunks was observed in 8% of the cases. Venous aneurysms also were present in 8% of the cases; avalvulia was recorded in 7% of the cases.

CONCLUSION

Anomalies of the deep venous system occur in almost one half of congenital vascular malformations of venous predominance. The most common is the relatively innocuous phlebectasias that occur in over one third of cases. Aplasia/hypoplasia, venous aneurysms, and avalvulia were less frequent, each less than 10%; but failure to detect the latter three anomalies may lead to serious therapeutic errors.

Selectivity of superficial vein occlusion at the ankle and calf level: a methodological study in healthy volunteers

Judgement of deep venous function may be necessary before surgery for superficial vein incompetence is performed. Assessment of deep venous function needs selective entrapment of superficial venous compartments between the ankle and knee, which may not be guaranteed if conventional tourniquets are used. This study was, therefore, aimed at modifying the technique of selective compression of superficial vein compartments. Twenty apparently normal legs of 10 volunteers were investigated on two study days. The subjects were in a supine position with the feet resting 30 cm above heart level. Ankle cuffs (3 cm wide) were placed just above the malleoli and stepwise inflated with air. The steady-state venous volume of the forefoot as a function of the pressure within the ankle cuff was measured with a mercury-in-rubber strain gauge. The maximum venous outflow velocity from the foot was also measured at each cuff pressure step after the addition of conventional thigh vein occlusion. The same protocol was used on the second study day: calf cuffs (3 cm wide) were then used instead of the ankle cuffs. In the forefoot, venous volume increased and the maximum venous outflow velocity decreased significantly either at ankle cuff pressures > 30 mmHg or at calf cuff pressures of > 60 mmHg. By using small cuffs, selective superficial vein occlusion seems to occur at cuff pressures ranging between 10 and 30 mmHg (ankle) and between 30 and 60 mmHg (calf), provided the feet are 30 cm above heart level. Higher cuff pressures seem to interact with deep venous function.