Venae perforantes: a clinical review

Initiation of reticular and spider veins, incompetent perforantes and varicose veins in the saphenous vein network of the rat

In an attempt to induce experimental varicosity, reverse perforant vein development was initiated in the rat leg by applying a chronic (14 and 32 weeks) partial stricture on the main branch of the deep femoral vein. At surfacing of the incompetent perforantes, typical reticular vein plaques and spider veins were identified by video-microscopy and quantitative histology. Deep vein blood was channeled by them into the saphenous vein system, the extra flow deforming these vessels, causing local dilations and broken course, even undulations of larger branches.

Evaluation of perforating venous insufficiency with shear wave elastography: a preliminary study

PURPOSE

The aim of this study was to investigate the efficacy of shear wave elastography (SWE) in the diagnosis of perforating vein insufficiency, and to determine the applicability of these measurements.

METHODS

A total of 140 symptomatic patients with a total of 280 lower extremities were investigated. All patients presented with venous insufficiency (VI) symptoms, and received Doppler ultrasound assessment to determine VI and SWE measurements. The SWE values were measured in the adjacent perivenous tissue of the largest Cockett's perforating vein (PV) of both lower extremities, at the level where they pass the fascia. The Cockett's PV diameter and the presence of reflux in Cockett's PV and the great saphenous vein were compared with SWE values in perivenous tissue of PVs.

RESULTS

The SWE values of the perforating vein insufficiency group were significantly higher than those of the normal PV without insufficiency group (P < 0.001). A significant and positive relation was seen between increased PV diameter and SWE values (P < 0.001) and there was a significant relationship between the presence of perforating vein insufficiency and increase in PV diameter. A statistically significant increase was detected in SWE values for the PV for those with reflux in the great saphenous vein (P < 0.001). The best cut-off values that can be used to detect perforating vein insufficiency were found 34.600 for kPa and 3.375 for m/s.

CONCLUSION

SWE may be used effectively in addition to conventional Doppler ultrasound examination in diagnosing and following perforating vein insufficiency.

Autogenously derived regenerative cell therapy for venous leg ulcers

Introduction

Venous leg ulcers (VLUs), which arise from chronic venous insufficiency in the lower limbs, are a major cause of morbidity and significantly negatively impact patients’ health-related quality of life. Treatment of venous ulcers can be either conservative or surgical. Despite appropriate treatment, VLUs can be resistant to healing. Clinical results of treatment of venous foot ulcers with adipose-derived autologous stem cells, which did not improve despite the surgical treatment of the underlying venous pathology in the following case series, are reported.

Material and methods

Between April 2015 and January 2016, a total of 31 patients who had undergone surgery for underlying venous pathology but the venous ulcer had not healed were included in the study. The mean venous ulcer size was 3.6–6.2 cm (range: 2 to 8 cm by 3 to 9 cm). All patients were treated with adipose-derived autologous stem cells prepared using the MyStem Regenerative Adipose-Derived Stem Cell Purification Kit (MyStem LLC, USA). The ulcer diameter was measured and recorded in the third, sixth and twelfth months. The follow-up time was 12 months after ulcer healing.

Results

Eighteen ulcers demonstrated complete healing at the 12^th month. Thirteen ulcers exhibited serious contraction and epithelialization even though the ulcer was not completely closed. At the 12^th month, the ulcer size was reduced by 96.00 ±1.74% in these patients. The reduction in the ulcer area based on the month analyzed was significant (p = 0.001; p < 0.01). After the ulcers healed, the patients were followed for recurrence for one year. Recurrent ulcers were observed at the treated sites in 3 of 31 patients (9%). No adverse events, such as infection, inflammation, or tissue reactions, were observed.

Conclusions

Application of cell therapy in venous leg ulcer is currently used exclusively in patients not responding to the standard treatment. Autogenously derived regenerative cell therapy for VLUs can be considered as an additional treatment to primary surgical therapy.

Frequency and Significance of Perforating Venous Insufficiency in Patients with Chronic Venous Insufficiency of Lower Extremity

OBJECTIVE

The aim of this study was to reveal the frequency and impact of perforating venous insufficiency (PVI) in chronic venous insufficiency (CVI) of lower extremity (LE).

MATERIALS AND METHODS

Between 2012 and 2017, a total of 1154 patients [781 females (67.68%) and 373 males (32.32%), 228 (19.76%) unilateral and 926 (80.24%) bilateral LE] were examined using Doppler ultrasound (US). A total of 2080 venous systems of LEs [31.4% male (n=653) and 68.6% female (n=1427); 1056 left LEs (50.77%) and 1024 right LEs (49.23%)] were examined. All patients had symptoms of venous insufficiency (VI).

RESULTS

PVI was revealed in 27.5% (n=571) of LEs. Varicose veins (VVs) related with perforating vein (PV) were revealed in 44.7% of LEs (n=929). PVI was observed in 50.91% of patients with chronic deep venous thrombosis (DVT), 64.41% with deep venous insufficiency (DVI), 59.81% with great saphenous vein (GSV) insufficiency, 68.49% with small saphenous vein (SSV) insufficiency, 58.65% with accessory GSV insufficiency, and 58.77% with PV associated with VVs. There was a statistically significant relationship between PVI and chronic DVT, DVI, GSV, SSV, and accessory GSV insufficiency (p<0.001). A significant relationship was observed between the increase in PV diameter and the presence of PVI (p<0.001).

CONCLUSION

PVI is quite common in combined VI, and PV evaluation should be a part of LE venous system examination.

Deep venous reflux associated with a dilated popliteal fossa vein reversed with endovenous laser ablation and sclerotherapy

Objective. To report an incidence of reflux in the deep venous system reversed by ablation of a popliteal fossa vein (PFV). Method. A 40-year-old man with pain and swelling in the medial upper calf was found to have an incompetent PFV. Results. Reflux in the femoral and popliteal veins was reversed utilizing endovenous laser ablation and foam sclerotherapy, documented on Duplex studies before and after the intervention. There was also resolution of symptoms. Conclusion. A PFV can be associated with deep venous reflux. Correction of this reflux with ablation of the PFV suggests that his type of reflux is secondary to volume effects of the incompetent popliteal vein.

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.

Color-Doppler sonography in chronic venous insufficiency: what the radiologist should know

Chronic venous insufficiency (CVI) is a pathologic condition caused by valvular incompetence, with or without associated venous outflow obstruction, which may affect both the superficial and the deep venous system, causing venous hypertension and stasis. The most common form of CVI is primary varicose veins due to the insufficiency of the saphenous system. Color-Doppler sonography (CDS) is actually the main diagnostic technique of imaging for CVI. In this article, we describe the anatomy, the technique, and the information necessary to the radiologist to perform CDS in chronic venous insufficiency. The knowledge of the venous anatomy is the cornerstone for an adequate sonographic examination. The venous network in the lower extremities is divided into three systems: superficial, deep, and perforating veins. Deep veins are "comitantes" to the corresponding arteries and run under the muscular fascia. Superficial veins course into the subcutaneous fat, superficially to the deep muscular fascia; the main superficial veins are the greater and lesser saphenous and their tributaries. Connection between the saphenous veins are defined as communicating veins. Superficial and deep veins are connected by perforating veins, with flow directed, under normal circumstances, from the superficial to the deep system. The main perforating are the Hunter in the mid thigh, the Dodd in the lower thigh, the Boyd in the upper calf, and the Cockett's in the middle and lower calf. Sonographic examination must be performed in the upright and supine position. Compression sonography and color and PW Doppler are systematically employed to assess the absence of deep venous thrombosis. Femoro-popliteal veins are evaluated with color and PW Doppler for valvular insufficiency with reflux by performing Valsalva maneuver and calf compression. The sapheno-femoral and sapheno-popliteal junctions are examined to identify type of junction, continence, accessory saphenous, and incompetent collaterals. Perforating veins are usually identified at the medial aspect of the thigh and at the medial, lateral, and posterior aspects of the leg. Outward flow (lasting more than 500 ms) in the perforating veins should be considered a sign of their incompetence. Several surgical and interventional procedures are now available for the treatment of the CVI, as follows: vein ligation and stripping, stab avulsion, endoluminal occlusion of the saphenous trunks, subfascial endoscopic perforator surgery, and valvuloplasty.

Perforans Varicosis: Treatment of the Incompetent Perforating Vein Is Important

BACKGROUND

Varicose veins that arise from incompetent perforating veins are called perforans-varicosis.

OBJECTIVE

This case report illustrates the relationship between incompetent perforating veins and varicosis.

METHODS

An incompetent perforating vein, proximal of a varicose vein located at the dorsal side of the thigh, was treated by means of ultrasound-guided sclerotherapy with 1% polidocanol foam. The varicose vein was not treated.

RESULTS

After 1 week, the varicose vein and the incompetent perforating vein showed no reflux. The varicose vein was practically invisible. The residual vein was treated with sclerotherapy. After 6 weeks the varicose vein was still invisible.

CONCLUSION

This proximal incompetent perforating vein was important for the development and maintenance of the varicose vein. Treatment of this incompetent perforating vein resulted in complete disappearance of the reflux in the varicose vein. In this case ultrasound-guided sclerotherapy was successful in treating the incompetent perforating vein. More studies are needed to investigate the long-term effect of ultrasound-guided sclerotherapy as treatment of perforans-varicosis.