Current concepts in chronic venous ulceration

Comprehensive Care of Lower-Extremity Wounds

There are 5 common types of chronic nonhealing lower-extremity wounds: arterial, venous, diabetic foot ulcer, pressure, and mixed or atypical. Each chronic wound type has distinct features, and understanding the underlying cause will dictate the wound treatment plan. Here, the authors review the distinguishing wound properties for these 5 common chronic nonhealing lower-extremity wounds and outline a comprehensive treatment plan that addresses wound perfusion, debridement, infection control, moisture balance, and use of complementary advanced wound care products.

Deep Venous Thrombosis and Ulcers of Lower Limbs: Ultrasound Findings in 156 Patients

Venous ulcers (VUs) of lower limbs affect 1% of Western population. In most cases, ultrasounds show only superficial venous insufficiency (SVI), but a deep venous insufficiency (DVI) may also be present without a history of deep vein thrombosis (DVT). To assess SVI and DVI in DVT-positive and DVT-negative patients with VU, a retrospective cohort of 123 patients entered the study (50 male and 73 female, minimum age 29 years and maximum age 90 years, and mean 70.6 years). In 56 patients (45.5%), ulcer was on the right leg, in 52 (42.3%) on the left leg, and in 15 patients (12.2%), ulcer was bilateral, resulting in a total number of 138 limbs in the study. Sixty-six patients suffered DVT, while in 72 anamnesis was negative. Color duplex ultrasound was performed on both limbs, which revealed insufficiencies of superficial and/or deep veins in 18 limbs which had not been affected by an ulcer or a previous DVT. So the study was on 156 limbs. SVI were substantially overlapping in two groups ( p -value = 0.593), while combined SVI and DVI was 72.5% in DVT positive limbs ( p -value = 0.001). In 70% of cases with a femoral vein insufficiency ( p -value = 0.036) or popliteal vein insufficiency (PVI) ( p -value 0,003), a DVT history was present. Of 18 limbs, although not affected by ulcer or previous DVT, eight were positive for DVI (two femoral veins and six popliteal veins). In the patient with VU, the history of DVT is a strong predictor of DVI insufficiency. In DVT-positive patients with ulcer, the number of "combined superficial and deep insufficiencies" appears to be particularly significant and surgical treatment must take this into account. A previous DVT has a low impact on great and small saphenous insufficiencies in ulcer patients; these were substantially overlapping in DVT-positive and DVT-negative patients. The 18 limbs with DVI and SVI without ulcer and DVT history were unexpected result. We think these patients must have a close follow-up to avoid the onset of a VU.

Biological autologous excised varicose vein dressing compared to conservative dressing on the ulcer bed during endovenous ablation

Objective

To compare the use of biological autologous excised varicose vein dressing ( VenoDress) compared to conservative dressing on the ulcer bed during endovenous ablation

Methods

This retrospective non-blinded study included all consecutive patients with primary or recurrent venous leg ulcers (VLU) with superficial varices treated in one center between September 2019 and October 2020. They all underwent venous ablation, wound debridement, and when needed phlebectomy. On the study group, the excised veins were incised, formed into a sheet, and applied onto the debrided wound bed with the endothelial side facing the wound bed. Adhesion was assessed weekly for 3 weeks. The study group was compared to a control group that underwent similar procedures but with the debrided wound bed treated with low-adherent paraffin dressing. The primary outcome was complete wound healing at 1 and 3 months, and the secondary outcomes were wound-related pain and leg edema.

Results

Complete wound closure was documented in 17/26 study group patients at 1 month (65%) and in 25/26 (96%) at 3 months. Complete wound closure was documented in 37/82 patients in the control group (45%) and in 67/82 (82%) at 3 months. The 1-month healing rates were significantly in favor of the VenoDress group when adjusted to sex and diabetes: odds ratio = 2.81 (1.05–7.532), p = .04. The preoperative pain level of the study group (as measured by a visual analog scale VAS (0–10) decreased from 4.96 ± 2.71 to 0.73 ± 1.36 at 1 week and that of the control group from 4.8 ± 2 to 1.35 ± 1.38 at 1 week ( p < .001).

Conclusion

the use of autologous varicose veins as dressing effectively reduced pain in VLU patients compared to conventional techniques. Although its effects on wound closure appear highly promising, further validation is warranted in a randomized comparative study.

Using Non-Contrast MRA to Discriminate between Obstructive and Nonobstructive Venous Diseases of the Legs

BACKGROUND

Venous interventions of the legs are less predictable owing to a lock of objective tools.

METHODS

One hundred and twenty patients with lower extremity venous disease were evaluated anatomically using TRANCE MRI. Then, a QFlow analysis was performed in 53 patients with only one leg affected for hemodynamic evaluation. Those patients with complete QFlow were classified into obstructive and nonobstructive.

RESULTS

The QFlow-namely, stroke volume, forward flow volume, mean flux, stroke distance (SD), and mean velocity (MV) in the external iliac vein (EIV), femoral vein (FV), popliteal vein (PV), and great saphenous vein (GSV). The obstructed group had a shorter SD and lower MV in the EIV, EIV/FV, and GSV/PV (SD: p-values of 0.025, 0.05, and 0.043, respectively; MV: p-values of 0.02, 0.05, and 0.048, respectively). A good performance in discriminating obstructive venous disease was reported for SD in the EIV (area under the curve (AUC) = 67.9%, 95% confidence interval (CI) = 53.2-82.7%), EIV/FV (AUC = 72.4%, 95% CI = 58.2-86.5%), and GSV/PV (AUC = 67.9%, 95% CI = 51.7-84.1%). The SD in the EIV, EIV/FV, and GSV/PV had the ability to discriminate between obstructive and nonobstructive diseases (p-values of 0.025, 0.005, and 0.043). The MV in the EIV, EIV/FV, and GSV/PV had ability to discriminate between obstructive and nonobstructive venous diseases (p-values of 0.02, 0.005, and 0.048).

CONCLUSIONS

The SD and MV were lower for obstructive than nonobstructive disease in the EIV.

Superficial Venous Reflux Intervention Guided by Triggered Angiography Non-Contrast-Enhanced Sequence Magnetic Resonance Imaging: Different QFlow Pattern from Health Controls

(1) Background: To assess the effectiveness of triggered angiography non-contrast-enhanced (TRANCE)-magnetic resonance imaging (MRI) in superficial venous reflux and its difference from health controls. (2) Methods: Thirty patients underwent TRANCE MRI before surgical intervention of their superficial venous reflux of the legs. Ten healthy volunteers were included as a control. (3) Results: TRANCE MRI involves the major tributaries, thus enhances the additional ablations in 20% of patients. QFlow pattern of superficial venous reflux (QFlow GSV/PV MF ratio > 1) was compared with the duplex scan (SFJ reflux) using Cohen’s kappa coefficient at 0.967. The 30 morbid legs undergoing TRANCE MRI-guide interventions and the healthy volunteers’ legs on the same side were compared. The stroke volumes (SV) are higher in EIV (p = 0.021) in the left-leg-intervention group. The mean flux (MF) is higher in the EIV (p = 0.012) and trend of increasing in GSV segment (p = 0.087) in the left-leg-intervention group. The QFlow of 10 patients with right leg intervention are higher in GSV in the right-leg-intervention group (SV p = 0.002; FFV p = 0.001; MF p = 0.001). QFlow data is shown for all legs for superficial venous intervention with GSV/PV (MF) ratio > 1. (4) Conclusions: Typical figures in QFlow (GSV/PV MF ratio > 1) could be observed in the morbid limbs but not in the controls.

The need for perforator treatment after VenaSeal and ClosureFast endovenous saphenous vein closure in CEAP 6 patients

OBJECTIVE

The authors have previously demonstrated that VenaSeal (Medtronic, Inc, Minneapolis, Minn) adhesive, compared with radiofrequency ablation (RFA, ClosureFast; Medtronic, Inc), in treatment of refluxing saphenous veins in CEAP 6 limbs, results in shorter healing times of venous ulcers. The authors hypothesize that the longer treated length possible with VenaSeal's nonthermal modality may affect the number of critical refluxing perforators contributing to the nonhealing wound. This follow-up study compares the need for follow-up treatment of perforator veins after saphenous vein treatment with either radiofrequency ablation (ClosureFast RFA) or adhesive closure (VenaSeal).

METHODS

A multi-institutional retrospective review of CEAP 6 patients who had closure of their saphenous veins from 2015 to 2020 was conducted. Patients who underwent follow-up treatment of perforator veins were grouped according to their method of initial management of their saphenous veins. The primary end point was incidence of a perforator procedure after ClosureFast or VenaSeal ablation. Secondary end points included sclerotherapy to facilitate wound healing. Bivariate analysis used the χ² test, Fisher exact test, t-test, and Wilcoxon rank sum test. A P value of <.05 defined statistical significance.

RESULTS

There were 119 CEAP 6 patients with saphenous closure: 51 limbs treated with VenaSeal and 68 with RFA. Median follow-up was 105 days (interquartile range: 44, 208). All limbs achieved wound healing during the study period. Mean time to wound healing post index procedure was shorter for VenaSeal than RFA (72 vs 293.8 days, P > .0009), as was median time (43 vs 104 days, P = .001). More limbs treated with RFA had previous known deep vein thrombosis (29% vs 10%, P = .009), deep venous insufficiency (82% vs 51%, P = .0003), and perforator reflux (57% vs 29%, P = .002). Limbs with identified follow-up perforator reflux treated with RFA had a higher prevalence of initially treated saphenous veins with RFA compared with those treated with VenaSeal (49% vs 27%, P = .003). There was no difference between the methods of vein closure and use of concurrent sclerotherapy.

CONCLUSIONS

ClosureFast and VenaSeal are both effective and safe modalities of saphenous ablation, but VenaSeal treatment was associated with less perforator RFA intervention.

Discriminating Reflux from Non-Reflux Diseases of Superficial Veins in Legs by Novel Non-Contrast MR with QFlow Technique

Objectives: To find an objective diagnostic tool for the superficial veins in legs. Methods: This study included 137 patients who underwent TRANCE-MRI from 2017 to 2020 (IRB: 202001570B0). Among them, 53 with unilateral leg venous diseases underwent a QFlow scan and were classified into the reflux and non-reflux groups according to the status of the great saphenous veins. Results: The QFlow, namely stroke volume (SV), forward flow volume (FFV), mean flux (MF), stroke distance (SD), and mean velocity (MV) measured in the external iliac, femoral, popliteal, and great saphenous vein (GSV). The SV, FFV, SD, MF, SD, and MV in the GSV (morbid/non-morbid limbs) demonstrated a favorable ability to discriminate reflux from non-reflux in the ROC curve. The SD in the GSV and GSV/PV ratio (p = 0.049 and 0.047/cutoff = 86 and 117.1) and the MV in the EIV/FV ratio, GSV, and GSV/PV ratio (p = 0.035, 0.034, and 0.025/cutoff = 100.9, 86.1, and 122.9) exhibited the ability to discriminate between reflux and non-reflux group. The SD, MV, and FFV have better ability to discriminate a reflux from non-reflux group than the SV and MF. Conclusions: QFlow may be used to verify the reflux of superficial veins in the legs. An increasing GSV/PV ratio is a hallmark of reflux of superficial veins in the legs.

Early versus deferred endovenous ablation of superficial venous reflux in patients with venous ulceration: the EVRA RCT

BACKGROUND

Venous ulceration is a common and costly health-care issue worldwide, with poor healing rates greatly affecting patient quality of life. Compression bandaging has been shown to improve healing rates and reduce recurrence, but does not address the underlying cause, which is often superficial venous reflux. Surgical correction of the reflux reduces ulcer recurrence; however, the effect of early endovenous ablation of superficial venous reflux on ulcer healing is unclear.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of compression therapy with early endovenous ablation of superficial venous reflux compared with compression therapy with deferred endovenous ablation in patients with venous ulceration.

DESIGN

A pragmatic, two-arm, multicentre, parallel-group, open randomised controlled trial with a health economic evaluation.

SETTING

Secondary care vascular centres in England.

PARTICIPANTS

Patients aged ≥ 18 years with a venous leg ulcer of between 6 weeks' and 6 months' duration and an ankle-brachial pressure index of ≥ 0.8 who could tolerate compression and were deemed suitable for endovenous ablation of superficial venous reflux.

INTERVENTIONS

Participants were randomised 1 : 1 to either early ablation (compression therapy and superficial endovenous ablation within 2 weeks of randomisation) or deferred ablation (compression therapy followed by endovenous ablation once the ulcer had healed).

MAIN OUTCOME MEASURES

The primary outcome measure was time from randomisation to ulcer healing, confirmed by blinded assessment. Secondary outcomes included 24-week ulcer healing rates, ulcer-free time, clinical success (in addition to quality of life), costs and quality-adjusted life-years (QALYs). All analyses were performed on an intention-to-treat basis.

RESULTS

A total of 450 participants were recruited (224 to early and 226 to deferred superficial endovenous ablation). Baseline characteristics were similar between the two groups. Time to ulcer healing was shorter in participants randomised to early superficial endovenous ablation than in those randomised to deferred ablation [hazard ratio 1.38, 95% confidence interval (CI) 1.13 to 1.68; p = 0.001]. Median time to ulcer healing was 56 (95% CI 49 to 66) days in the early ablation group and 82 (95% CI 69 to 92) days in the deferred ablation group. The ulcer healing rate at 24 weeks was 85.6% in the early ablation group, compared with 76.3% in the deferred ablation group. Median ulcer-free time was 306 [interquartile range (IQR) 240-328] days in the early ablation group and 278 (IQR 175-324) days in the deferred endovenous ablation group (p = 0.002). The most common complications of superficial endovenous ablation were pain and deep-vein thrombosis. Differences in repeated measures of Aberdeen Varicose Vein Questionnaire scores (p < 0.001), EuroQol-5 Dimensions index values (p = 0.03) and Short Form questionnaire-36 items body pain (p = 0.05) over the follow-up period were observed, in favour of early ablation. The mean difference in total costs between the early ablation and deferred ablation groups was £163 [standard error (SE) £318; p = 0.607]; however, there was a substantial and statistically significant gain in QALY over 1 year [mean difference between groups 0.041 (SE 0.017) QALYs; p = 0.017]. The incremental cost-effectiveness ratio of early ablation at 1 year was £3976 per QALY, with a high probability (89%) of being more cost-effective than deferred ablation at conventional UK decision-making thresholds (currently £20,000 per QALY). Sensitivity analyses using alternative statistical models give qualitatively similar results.

LIMITATIONS

Only 7% of screened patients were recruited, treatment regimens varied significantly and technical success was assessed only in the early ablation group.

CONCLUSIONS

Early endovenous ablation of superficial venous reflux, in addition to compression therapy and wound dressings, reduces the time to healing of venous leg ulcers, increases ulcer-free time and is highly likely to be cost-effective.

FUTURE WORK

Longer-term follow-up is ongoing and will determine if early ablation will affect recurrence rates in the medium and long term.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02335796.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 24. See the NIHR Journals Library website for further project information.

Distribution patterns of pathological venous reflux and risk factors in patients with skin changes due to primary venous disease in North India

OBJECTIVES

To determine the distribution patterns of pathological venous reflux and risk factors in patients with skin changes due to primary venous disease.

METHODS

Two hundred limbs belonging to C4, C5 & C6 classes were examined with duplex ultrasound to determine the sites of reflux. We also analyzed the correlation of risk factors with patterns and severity of disease.

RESULTS

Among 200 limbs, superficial system reflux was found in 163 limbs (81.5%), deep system reflux in 10 limbs (5%) and perforator system reflux in 180 limbs (90%). The most common pattern of abnormality was combined superficial and perforator system reflux. Of all the risk factors, prolonged standing, obesity and in the female history of pregnancy preceding varicose occurrence had the highest prevalence.

CONCLUSIONS

In patients with primary chronic venous disease, lifestyle modification is required to avoid risk associated with obesity and prolonged standing. The higher prevalence of pathological perforator reflux in association with advanced venous disease necessitates careful treatment of this least reported pathology to achieve better treatment results.

Subfascial endoscopic perforator surgery (SEPS) for treating venous leg ulcers

BACKGROUND

Venous leg ulcers are complex, costly, and their prevalence is expected to increase as populations age. Venous congestion is a possible cause of venous leg ulcers, which subfascial endoscopic perforator surgery (SEPS) attempts to address by removing the connection between deep and superficial veins (perforator veins). The effectiveness of SEPS in the treatment of venous leg ulcers, however, is unclear.

OBJECTIVES

To assess the benefits and harms of subfascial endoscopic perforator surgery (SEPS) for the treatment of venous leg ulcers.

SEARCH METHODS

In March 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions that examined the use of SEPS independently or in combination with another intervention for the treatment of venous leg ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, assessed risk of bias, and assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included four RCTs with a total of 322 participants. There were three different comparators: SEPS plus compression therapy versus compression therapy (two trials); SEPS versus the Linton procedure (a type of open surgery) (one trial); and SEPS plus saphenous surgery versus saphenous surgery (one trial). The age range of participants was 30 to 82, with an equal spread of male and female participants. All trials were conducted in hospital settings with varying durations of follow-up, from 18 months to 6 years. One trial included participants who had both healed and active ulcers, with the rest including only participants with active ulcers.There was the potential for reporting bias in all trials and performance bias and detection bias in three trials. Participants in the fourth trial received one of two surgical procedures, and this study was at low risk of performance bias and detection bias.SEPS + compression therapy versus compression therapy (2 studies; 208 participants)There may be an increase in the proportion of healed ulcers at 24 months in people treated with SEPS and compression therapy compared with compression therapy alone (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.03 to 1.33; 1 study; 196 participants); low-certainty evidence (downgraded twice, once for risk of bias and once for imprecision).It is uncertain whether SEPS reduces the risk of ulcer recurrence at 24 months (RR 0.85, 95% CI 0.26 to 2.76; 2 studies; 208 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).The included trials did not measure or report the following outcomes; time to complete healing, health-related quality of life (HRQOL), adverse events, pain, duration of hospitalisation, and district nursing care requirements.SEPS versus Linton approach (1 study; 39 participants)It is uncertain whether there is a difference in ulcer healing at 24 months between participants treated with SEPS and those treated with the Linton procedure (RR 0.95, 95% CI 0.83 to 1.09; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).It is also uncertain whether there is a difference in risk of recurrence at 60 months: (RR 0.47, 95% CI 0.10 to 2.30; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).The Linton procedure is possibly associated with more adverse events than SEPS (RR 0.04, 95% CI 0.00 to 0.60; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).The outcomes time to complete healing, HRQOL, pain, duration of hospitalisation and district nursing care requirements were either not measured, reported or data were not available for analysis.SEPS + saphenous surgery versus saphenous surgery (1 study; 75 participants)It is uncertain whether there is a difference in ulcer healing at 12 months between participants treated with SEPS and saphenous surgery versus those treated with saphenous surgery alone (RR 0.96, 95% CI 0.64 to 1.43; 1 study; 22 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias).It is also uncertain whether there is a difference in the risk of recurrence at 12 months: (RR 1.03, 95% CI 0.15 to 6.91; 1 study; 75 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias).Finally, we are uncertain whether there is an increase in adverse events in the SEPS group (RR 2.05, 95% CI 0.86 to 4.90; 1 study; 75 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias).The outcomes time to complete healing, HRQOL, serious adverse events, pain, duration of hospitalisation, and district nursing care requirements were either not measured, reported or data were not available for analysis.

AUTHORS' CONCLUSIONS

The role of SEPS for the treatment of venous leg ulcers remains uncertain. Only low or very low-certainty evidence was available for inclusion. Due to small sample sizes and risk of bias in the included studies, we were unable to determine the potential benefits and harms of SEPS for this purpose. Only four studies met our inclusion criteria, three were very small, and one was poorly reported. Further high-quality studies addressing the use of SEPS in venous leg ulcer management are likely to change the conclusions of this review.

Patterns of Venous Reflux and Obstruction in Patients With Skin Damage Due to Chronic Venous Disease

Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease ( P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group ( P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls ( P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.

A comparison of the effectiveness of treating those with and without the complications of superficial venous insufficiency

OBJECTIVE

To test the hypothesis that patients with soft tissue changes related to superficial venous insufficiency (SVI) have greater benefits from treatment than those with only symptomatic varicose veins.

BACKGROUND

A commonly held view is that SVI is only a minor ailment, yet randomized clinical trials (RCTs) show that treatment improves quality of life (QoL) and is cost-effective. In an effort to curb the treatment costs of this common disorder, rationing is applied in many health care systems, often limiting the reimbursement of treatment to those with soft tissue changes.

METHODS

This cohort study draws its data from an interventional RCT. After informed consent, consecutive patients with symptomatic unilateral SVI were randomized to receive surgical ligation and stripping or endovenous laser ablation. This analysis differentially studies the outcomes of patients with simple varicose veins (C2: n = 191) and soft tissue complications (C3-4: n = 76). Effectiveness outcomes measured up to 1 year included the following: Qol [short form 36 (SF36), EuroQol, and the Aberdeen Varicose Veins Questionnaire], clinical recurrence, and the need for secondary procedures. Multivariable regression analysis was used to control for potential confounding factors.

RESULTS

Both groups saw significant improvements in QoL. All improvements were equal between groups apart from the SF36 domain of Bodily Pain, where C2 saw an improvement of 12.8 [95% confidence interval (CI): 4.8-20.8] points over C3-4 participants (P = 0.002), who also suffered more recurrence [odds ratio (OR) = 2.7, 95% CI: 1.2-6.1, P = 0.022] and required more secondary procedures (OR = 4.4, 95% CI: 1.2-16.3, P = 0.028).

CONCLUSIONS

This study suggests that rationing by clinical severity contradicts the evidence. Delaying treatment until the development of skin damage leads to a degree of irreversible morbidity and greater recurrence.

TRIAL REGISTRATION

NCT00759434 Clinicaltrials.gov.

Causes of recurrent lower limb varicose veins after surgical interventions in 141 limbs – Five-year retrospective analysis of two centers

Aim

The purpose of this study was to explore the causes of recurrent lower limb varicose veins after surgical interventions.

Methods

A retrospective five-year survey was conducted on patients who underwent second surgery due to recurrent lower limb varicose veins after surgical interventions. A total of 141 limbs (112 cases), including 72 cases of left lower limbs, 47 of right lower limbs and 22 of both limbs, were involved in the study. All patients underwent lower limb venography (141 limbs were anterograde and 28 cases were retrograde), and then examined with color-Doppler ultrasound.

Results

The major causes that urged patients to undergo second surgery are clinical changes graded above CEAP IV (93.6%), limb edema without changes on skin (5%), and single varicosity (1.4%). Up to 127 (83%) limbs exhibited perforating venous reflux, 67 (47.5%) limbs had varied degrees of deep venous insufficiency and 68 (48.2%) limbs had through or above-the-knee great saphenous vein trunk residual.

Conclusions

Preoperative venography before operation is indispensible in confirming the diagnosis and operation strategies. Patients with severe primary deep venous reflux and symptoms up to C3 may need simultaneous repair of the deep venous valves.

Bioactive polymer scaffold for fabrication of vascularized engineering tissue

Tissue engineering seeks strategies to design polymeric scaffolds that allow high-cell-density cultures with signaling molecules and suitable vascular supply. One major obstacle in tissue engineering is the inability to create thick engineered-tissue constructs. A pre-vascularized tissue scaffold appears to be the most favorable approach to avoid nutrient and oxygen supply limitations as well as to allow waste removal, factors that are often hurdles in developing thick engineered tissues. Vascularization can be achieved using strategies in which cells are cultured in bioactive polymer scaffolds that can mimic extracellular matrix environments. This review addresses recent advances and future challenges in developing and using bioactive polymer scaffolds to promote tissue construct vascularization.

Ultrasound Doppler evaluation of the pattern of involvement of varicose veins in Indian patients

Doppler evaluation of lower limb veins was performed to evaluate the pattern of involvement of various sites of incompetence in Indian patients with varicose veins. A prospective Doppler study of 100 consecutive limbs in patients who presented with varicose veins to the vascular surgery department of a tertiary care hospital in India. The Clinico-Etiological Anatomical and Pathological (CEAP) classification was applied for assessment. Doppler evaluation of both superficial and deep venous system of the lower limbs was performed. The data of various sites of reflux was analysed to find the patterns of venous involvement in the affected patients. Superficial venous reflux was seen in all the patients. Deep venous reflux was seen in 50% of the lower limbs examined. Doppler is a simple non-invasive test, and is well tolerated by the patients. Deep venous reflux is common in Indian population, though it rarely occurs in isolation, and is usually associated with superficial reflux.

Superficial vein ablation for the treatment of primary chronic venous ulcers

Objective

This retrospective study was undertaken to review our experience with ablation of superficial veins with significant reflux, using VNUS ClosureFAST RF (radiofrequency) or laser 980 nm, in patients with primary chronic venous ulcers, and also determine its effects in ulcer healing and ulcer recurrence.

Method

Included were 25 limbs (18 patients with chronic primary venous ulcers (clinical, aetiological, anatomical and pathological elements [CEAP] classification C6), who underwent endovenous ablation with RF for the axial veins or laser for the perforating veins during a two-year period.

Results

Of the 18 patients, there were eight men and 10 women. The median age of the group was 68 (range 37–89) years. The number of ablations done in each leg with an ulcer varied from one to eight, with a median of three. During a follow-up period of 6–12 months, one patient failed ulcer healing despite sequential ablations of refluxing veins. There was one case that developed recurrence of a small ulcer after six months and was successfully treated with a perforator ablation.

Conclusion

Endovenous ablation of incompetent superficial veins improves the healing of chronic primary venous ulcers and decreases the recurrence rates.

Identifying the source of superficial reflux in venous leg ulcers using duplex ultrasound

OBJECTIVE

Mapping of venous reflux routes associated with medially or laterally located venous leg ulcers and their source of origin.

METHODS

This prospective report presents the results of duplex investigations performed in consecutive leg ulcer patients, all with venous reflux, in a time period over 2 years. A total of 169 patients (183 legs), with chronic venous leg ulcers (CEAP: C6) were examined in a private practice. The data collection integrated an examination that included medical history and clinical diagnoses and incorporated measurements such as body mass index, oscillometric index, and range of motion of the ankle joint. Venous function was assessed with duplex ultrasound, and the cases were described using the advanced CEAP classification. Additionally, a "sourcing" technique was performed with duplex ultrasound investigation of the ulcer bed and the venous system under manual compression and release of the ulcer. The principle of "sourcing" is to follow venous reflux from the ulcer area to its proximal origin. The detected reflux routes were classified either as "axial" or "crossover" type.

RESULTS

A total of 20% of the ulcer patients showed no clinically visible varicose veins. One hundred three patients had medial ulcers, 54 lateral ulcers, 21 medial and lateral, and five had gaiter ulcers. Sixty-four (35%) of the medially located ulcers had reflux in the great saphenous vein (GSV), 28 (15%) showed reflux in the medial perforating veins (axial types), and 11 (6%) had reflux in the small saphenous vein (SSV; crossover type). From 54 patients presenting with lateral ulcers, 25 (14%) showed GSV incompetence (crossover type) and only 13 (7%) SSV incompetence (axial type). Sixteen patients showed refluxes penetrating from deep into lateral perforating veins.

CONCLUSION

Crossover reflux routes were detected in 25 of 54 (46%) legs with lateral and in 11 of 103 (11%) legs with medial ulceration (χ2 44.34; P<.001). In venous ulcer patients, an extended examination (CEAP classification) and a special duplex technique ("sourcing") are recommended to identify the specific route responsible for the venous reflux. This seems essential for planning a rational treatment of venous reflux ulcers.

The Impact of Valvular Oxidative Stress on the Development of Venous Stasis Ulcer Valvular Oxidative Stress and Venous Ulcers

Background: It is widely believed that venous ulcers result from venous insufficiency related to venous valve damages. To further investigate the pathogenesis of venous ulcers, we compared the influence of oxidative stress in venous valvular tissue on stasis ulcer formation in patients with venous ulcers secondary to superficial venous reflux disease. Methods: Thirty-nine consecutive patients with superficial venous reflux who underwent saphenectomy were included in the study. Patients were divided into 2 groups: with healed venous ulcers (group 1, n = 15) and without ulcers (group 2, n = 24). All patients were preoperatively evaluated with duplex ultrasound scanning and their blood samples were obtained to examine leukocyte count, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP) levels. All patients underwent standard above-knee saphenectomy. Extracted saphenous vein segments were from the saphenofemoral junction, the first valve along. The biochemical analysis of the valve tissues included matrix metalloproteinase (MMP)-9, MMP-2, IL-6, TNF-α, superoxide dismutase (SOD), malondialdehyde (MDA), and nitric oxide (NO) studies. Results: There was no significant difference between patients in terms of age, gender, hospital stay, and preoperative blood levels of leukocyte, IL-6, TNF-α, and CRP (P > .05). Biochemical examination of valve tissue showed that the levels of MMP-9, MMP-2, IL-6, TNF-α, SOD, MDA, and NO in patients with healing venous ulcer were higher than those of the second group. Conclusion: A higher oxidative stress in the valvular tissue may contribute to venous stasis ulcer formation.

Midterm Follow-up After Pharmacomechanical Thrombolysis for Lower Extremity Deep Venous Thrombosis

Objective: To provide follow-up in patients treated with pharmacomechanical thrombolysis (PhMT) for lower extremity deep venous thrombosis (DVT). Methods: Retrospective analysis of prospectively collected data. Patients underwent clinical evaluation, duplex ultrasound, venous clinical severity scoring, venous segmental disease scoring, and venous disability scoring. Results: Fourteen patients were available for evaluation. Median age was 40 years (19—58). Median follow-up was 24 months (13—69 months). Thirteen of 14 patients (93%) had a venous disability score < 1 and 13 of 14 patients (93%) had a venous clinical severity scoring < 5. In all but 1 patient the venous segmental disease scoring score was < 5. All iliac segments were patent, all but 3 patients had partial infrainguinal obstruction and 5 of 14 (36%) had reflux. Conclusions: Our data demonstrate that the good early clinical results after PhMT can be sustained on longer follow-up and may prevent the development of advanced postthrombotic syndrome.

Postthrombotic or non-postthrombotic severe venous insufficiency: impact of removal of superficial venous reflux with or without subcutaneous fasciotomy

BACKGROUND

Severe chronic venous insufficiency is often associated with therapy-resistant or recurrent venous leg ulcers, either as a result of deep vein thrombosis (DVT)- (postthrombotic syndrome [PTS]) or superficial venous insufficiency (SVI). Frequently present dermatoliposclerosis affects the skin as well as the subcutaneous and subfascial structures, which may impact tissue pressures and compromise skin perfusion. This study was undertaken to measure tissue pressures in PTS and SVI limbs and to evaluate the impact of removal of superficial venous reflux with or without concomitant subcutaneous fasciotomy.

MATERIAL

In eight patients with recurrent, therapy-resistant venous leg ulcers, due to PTS (11 limbs, 12 ulcers) and 14 patients with severe SVI (14 limbs, 14 ulcers), subcutaneous fasciotomy was performed in addition to removal of superficial reflux. They were compared with eight patients with PTS (11 limbs, 11 ulcers) and 10 patients with SVI (13 limbs, 13 ulcers) who did not have fasciotomy in addition to removal of their superficial venous reflux. Intramuscular (i.m.) and subcutaneous (s.c.) tissue pressures and transcutaneous oxygen tension (TcPO(2)) were measured prior to, immediately after, and 3 months following the surgical intervention. Healing of ulcer (spontaneous or by skin grafting) at 3 months was also observed.

RESULTS

There were no statistical differences between the groups regarding gender and age distribution or ulcer age at the time of surgery. All patients had in addition to surgery compression stockings class II (30 mm Hg). The i.m. tissue pressure was higher in patients with PTS compared with SVI patients, while s.c. tissue pressure and TcPO(2) did not differ between the groups. When fasciotomy was performed, i.m. and s.c. tissue pressures decreased and TcPO(2) increased significantly. Without fasciotomy, only s.c. tissue pressure decreased first at 3 months postoperatively. In the SVI-group, i.m tissue pressure was significantly decreased at 3 months in the group without fasciotomy.

CONCLUSIONS

Patients with severe chronic venous insufficiency with therapy-resistant or recurrent ulcer disease due to deep and superficial insufficiency have higher i.m. tissue pressures than patients with only superficial venous reflux, even though both groups have higher i.m. and s.c. tissue pressures compared with normal values. Eradication of all superficial reflux lowers s.c. tissue pressure, while additional fasciotomy lowers both i.m. and s.c. tissue pressures and increases TcPO(2), which seems to promote ulcer healing.

Emergency Management of Chronic Wounds

As America's emergency departments witness an increase in care provided to an aging population, the emergency physician increasingly evaluates and treats manifestations of chronic disease. Nonhealing wounds are often a presenting manifestation of chronic disease. They are a source of pain and disability for this population. Emergency physicians should possess a fundamental knowledge in the management of chronic wounds. This article familiarizes the emergency physician with the epidemiology of chronic wounds, the physiology of tissue repair, the pathophysiology involved in wound healing failure, the common types of chronic wounds, and specific management strategies.

Hemodynamic impairment, venous segmental disease, and clinical severity scoring in limbs with Klippel-Trenaunay syndrome

BACKGROUND

Klippel-Trenaunay syndrome (KTS) is a complex congenital anomaly featuring two or more of the following: (1) capillary malformations (port-wine stains), (2) soft tissue or bony hypertrophy (or both), and (3) varicose veins or venous malformations. With the purpose of determining the actual significance of venous impairment in patients with KTS, we quantified the venous valvular competency and calf muscle pump function and examined their effect on clinical severity.

METHODS

Included were patients with near-normal function of affected limb(s) and minimal/small foot hypertrophy. Excluded were those with deep venous hypoplasia, aplasia or thrombosis, lymphedema, limb length discrepancy (>2.5 cm), peripheral arterial (ankle-brachial index <1.0), or cardiac disease and walking impairment. Venous duplex scanning, ascending venography, magnetic resonance imaging, strain gauge plethysmography, and a bone scanogram were performed. We studied eight men and seven women aged 15 to 51 years (median, 24 years). The KTS involved 17 limbs (unilateral in 13 patients and bilateral in 2). Contralateral limbs in patients with unilateral KTS acted as controls (n = 13). Venous clinical severity was graded according to the CEAP and venous clinical severity score (VCSS), and reflux complexity was classified according to the venous segmental disease score. Outflow obstruction (outflow fraction at 1 and 4 seconds; OF(1) and OF(4), respectively), reflux (venous filling index), calf muscle pump function (ejection fraction), and hypertension (residual volume fraction) were determined in both limbs with strain gauge plethysmography. Data, reported as median and interquartile range, were analyzed with the Mann-Whitney test.

RESULTS

Varicose veins or venous malformations occurred in the medial, posterior, or anterolateral limb segments of the ankle (7/17, 7/17, and 9/17), calf (10/17, 8/17, and 12/17), knee (9/17, 8/17, and 8/17), and thigh (10/17, 6/17, and 8/17, respectively). Venous malformations occupied the subcutaneous space (17/17) and extended into the subfascial space in 6 (35.3%) of 17 limbs. Abnormal reflux (>0.5 seconds) was distributed in the great (64.7%; 11/17) and small (5.9%; 1/17) saphenous veins and the common femoral (23.5%; 4/17), femoral (41.1%; 7/17), popliteal (29.4%; 5/17), perforator (70.6%; 12/17), and axial calf (35.3%; 6/17) veins. There was no difference in the OF(1) and OF(4) between the affected limbs and the controls. Limbs with KTS had a fivefold greater venous filling index (0.133-0.46 mL . 100 mL(-1) . s(-1); 0.258 mL . 100 mL(-1) . s(-1)) than the controls (0.034-0.055 mL . 100 mL(-1) . s(-1); 0.046 mL . 100 mL(-1) . s(-1); P < .0001), and this was linked to a higher venous segmental disease score (3 [2-4] vs 0 [0-1]; P < .0001). Limbs with KTS had half the ejection fraction (20.8%; 12.3%-24%) of the controls (39.3%; 30.9%-64.6%) and twice as high a residual venous fraction (77% [69.6%-84.5%] vs 40.9% [20.6%-60%]; both P < .004). Patients complained of swelling (100%; 15/15), aching (100%; 15/15), pain (93.3%; 14/15) and heaviness (100%; 15/15), tiredness (66.7%; 10/15), and tightness (33.3%; 5/15) of the limb(s) with KTS. Limbs with KTS had a worse (1) venous clinical severity by 11 VCSS points (11 [8-12] vs 0 [0-1]) and (2) clinical status by 3 CEAP classes (C3 [C3-C4] vs C0 [C0-C2]) than the control limbs (both P < .0001).

CONCLUSIONS

Venous disease in limbs with KTS is a major source of morbidity in affected patients. Limbs with KTS are characterized by complex reflux patterns, severe valvular incompetence, calf muscle pump impairment, and venous hypertension, thus explaining the advanced clinical severity (VCSS) and CEAP grade.

The role of superficial venous operations for leg ulceration

Venous ulceration is a common clinical problem with high recurrence rates. The role of operative treatment to correct superficial reflux in venous ulceration remains unclear. This review reports current evidence for superficial surgical procedures in the treatment of venous ulceration.

Current management of venous ulceration

It has been estimated that chronic venous insufficiency affects 10 to 35 percent of the entire U.S. population and that 4 percent of people older than 65 have active venous ulcers. The high prevalence of the disease results in an annual expenditure of more than 1 billion dollars a year to the U.S. health care system. To have a rational approach toward patients with venous ulcers, it is important to understand the pathophysiology and clinical characteristics of the disease process, in order to initiate appropriate treatment and prevent venous ulcer recurrence.

Service comparison between vascular and general surgery in the treatment of chronic venous insufficiency with special reference to preoperative Doppler techniques

AIMS

To compare the ability of vascular and general surgical services to abolish reflux in superficial venous system with a special reference to preoperative use of Doppler techniques.

MATERIALS AND METHODS

68 lower limbs operated on for venous insufficiency based on either preoperative Duplex evaluation and Doppler marking in a vascular surgical unit (Vascular Surgical Service, VSS: 33 limbs, clinical class C2-C6) or clinical findings in a general surgical unit (General Surgical Service, GSS: 35 limbs, clinical class C2-C4) were re-examined clinically and with duplex scanning for reflux some three years postoperatively.

RESULTS

Marked superficial or perforator vein reflux was observed in 27 of 68 (39.7 %) operated limbs, thirteen of which in VSS and fourteen in GSS. However, axial reflux at saphenofemoral or thigh level was observed significantly less in VSS compared to GSS (3 vs 13, p = 0,006).

CONCLUSION

Total ablation of any reflux appeared difficult irrespective of the preoperative assessment. Preoperative Duplex examination, however, aided in identifying and treating axial reflux at thigh level.

Reduction in deep vein reflux after concomitant subfascial endoscopic perforating vein surgery and superficial vein ablation in advanced primary chronic venous insufficiency

BACKGROUND

Subfascial endoscopic perforating vein surgery (SEPS) and superficial vein surgery (SVS) have been the recommended treatment for advanced chronic venous insufficiency (CVI), despite a high prevalence of deep vein reflux in these patients. The anatomic and hemodynamic results of these procedures, however, remain uncertain. It is hypothesized that concomitant SEPS and SVS would result in a reduction of deep vein reflux in patients with advanced primary CVI. We investigated the effect of concomitant SEPS and SVS on deep vein reflux as well as the associated hemodynamic and clinical changes after surgery in a cohort of patients with advanced primary CVI.

METHODS

We prospectively evaluated 53 consecutive SEPSs with concomitant SVS procedures in 47 patients with advanced primary CVI. There were 25 men and 22 women with a mean age of 58 years at operation. Thirty-four procedures (64%) were performed for limbs with active venous ulcers (class 6), and the other 19 procedures were performed for 15 class 5 limbs, one class 4a limb, and three class 4b limbs, respectively. Duplex scan and air plethysmography were performed before operation, at 1 month, and at 1 year after operation. The patients were followed up regularly with clinical assessment, and the ulcer healing and recurrence rates were documented.

RESULTS

The proportion of limbs with common femoral vein incompetence decreased from 68% to 28% at 1 month and to 32% at 1 year after operation. The proportion of limbs with deep vein incompetence at more than one site also decreased from 42% to 15% at 1 month and to 12% at 1 year after concomitant SEPS and SVS. Venous hemodynamics as measured by air plethysmography improved significantly after operation. The cumulative ulcer healing was 85% at 3 months and 97% at 6 months. With a mean follow-up of 31 +/- 16 months, all ulcers healed. Only three recurrent ulcers (6%) were detected during the follow-up period.

CONCLUSION

Concomitant SEPS and SVS are effective in reducing deep vein reflux and results in hemodynamic and clinical improvements in patients with advanced primary CVI. Deep vein reconstruction procedures may not be necessary in these patients.

Perforator vein incompetence in chronic venous disease: A multivariate regression analysis model

OBJECTIVES

In the presence of superficial and deep vein insufficiency the effects, if any, of concurrent incompetent perforator veins (IPVs) on clinical status are masked. On the basis of multivariate regression analysis, this study examines the significance of perforator vein incompetence across the clinical classes of CEAP (C-class CEAP ) in relation to the superficial and deep systems, and assesses the role of factors implicated in the presence and number of IPVs in chronic venous disease (CVD).

METHODS

The study included 525 limbs in 360 patients, ages 17 to 96 years, referred for investigation of CVD. The protocol entailed history taking, physical examination, and duplex scanning (reflux > 0.5 s), with emphasis on IPVs. Exclusion criteria included peripheral vascular disease, unrelated edema, severe chronic obstructive pulmonary disease, and recent (< 1 year) deep vein thrombosis (DVT).

RESULTS

Limbs were stratified as C 0 , 84; C 1 , 25; C 2 , 231; C 3 , 66; C 4 , 48; C 5 , 23; and C 6 , 48. C-class CEAP was separately regressed with age ( P < .001), sex ( P < .25), contralateral CVD ( P < .2), CVD recurrence ( P = .022), previous DVT ( P < .001), superficial vein reflux ( P < .001); deep vein reflux ( P < .001), perforator vein reflux ( P < .001), and number of IPVs ( P < .001). In an optimized multivariate regression analysis of C class CEAP with all significant variables combined, age ( P < .001), previous DVT ( P = .017), superficial vein reflux ( P < .001), deep vein reflux ( P < .001), and number of IPVs ( P = .008) emerged as predictors of CVD severity (CEAP), based on the equation C class CEAP = -0.2807 + 0.028013 Age + 0.58530 Previous DVT + 0.3450 Superficial vein reflux + 0.17781 Deep Reflux + 0.14537 IPVs ( R 2 = 37.4%; P < .001). Perforator incompetence was predicted by superficial vein reflux ( P < .001) and deep vein reflux ( P = .044), age ( P = .019), CVD recurrence ( P = .038), and sex ( P = .018), as follows: Perforator incompetence = -0.2532 + 0.006457 Age + 0.41366 Superficial reflux + 0.06766 Deep reflux + 0.2450 CVD recurrence - 0.21310 Sex ( R 2 = 33.3%; P < .001). Number of IPVs per limb was best associated with superficial reflux ( P < .001) and deep reflux ( P = .023), linked as IPVs = - 0.11789 + 0.41323 Superficial reflux + 0.07646 Deep reflux ( R 2 = 26.1%; P < .001).

CONCLUSION

Perforator incompetence proved to be a significant factor for determination of CVD severity according to C-class CEAP , withstanding the conspicuous confounding effects of the superficial and deep venous systems. Perforator incompetence was significantly linked to aging, superficial or deep vein incompetence, recurrence of superficial disease, and sex, whereas the IPV number, regardless of location, depended on the presence of superficial or deep venous reflux.

The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic

OBJECTIVES

accurate diagnosis is essential if patients with chronic leg ulceration are to receive optimal treatment. This prospective study describes the findings of a standardised assessment protocol and the initial management of a consecutive series of patients with chronic leg ulceration presenting to a single-visit leg ulcer assessment clinic.

METHODS

between January 1993 and January 1999, a total of 555 patients (220 men and 335 women of median age 73, range 28-95 years) with 689 chronic leg ulcers were assessed. Full clinical assessment, ankle:brachial pressure index and lower limb venous duplex scan were performed according to a standardised protocol and diagnostic and management data were recorded prospectively on a computerised database.

RESULTS

venous disease alone was responsible for 496 of 689 (72%) ulcers. Isolated superficial venous reflux (SVR) was identified in 52% of limbs and two-thirds of these had superficial venous surgery. Combined SVR and segmental deep venous reflux (DVR) was present in 13%, and full-length DVR was present in 33% of limbs. Nineteen (4%) limbs had deep venous stenosis or obstruction. Overall, superficial venous surgery was performed in 43% and compression bandages or hosiery alone were applied in 52% of limbs. Mixed arterio-venous ulceration was present in 100 (14.5%) limbs of which 56 had arterial revascularisation, 38 had superficial venous surgery and 23 had compression alone. Fifteen limbs with pure arterial ulceration had angioplasty (n=13) or simple dressings alone (n=2). Ulceration due to lymphoedema (n=17), mixed lymphoedema and venous reflux (n=11) and other causes (n=50) were managed by compression, dressings or skin grafting.

CONCLUSIONS

a standardised protocol of clinical and duplex assessment can lead to a diagnosis in 97% of chronic leg ulcers. Duplex is essential to confirm or exclude potentially correctable venous disease and allow tailored surgical intervention for those patients who many benefit.

Optimal therapy for advanced chronic venous insufficiency

INTRODUCTION

While definitive therapy awaits level I evidence, controversy persists regarding the optimal operation for treatment of advanced chronic venous insufficiency (CVI). We propose a pragmatic approach to the correction or amelioration of venous hypertension resulting from hydrodynamic and hydrostatic venous reflux. We evaluated a strategy of balloon dissection, subfascial endoscopic perforating vein surgery (SEPS) with routine posterior deep compartment fasciotomy, including ligation and stripping of the superficial system, for use when reflux is documented at duplex ultrasound (US) scanning.

METHODS

This is a cooperative, multicenter, retrospective review of 832 patients stratified by CEAP classification. The series consisted of 300 patients with C4 CVI, 119 patients with C5 CVI, and 413 patients with C6 CVI. A subset of 92 patients with C4 disease were prospectively randomized, and ambulatory venous pressure (AVP) was determined preoperatively and postoperatively. All patients underwent duplex US scanning to document reflux in the deep, superficial, and perforating venous systems. Efficacy, safety, and durability were evaluated over follow-up of 1 to 9 years (mean, 31/2 years). Uniformity was attempted by adoption of the senior author's protocol and technique through on-site preceptorship in each surgeon's operative theater.

RESULTS

This technique interrupted 3 to 14 (mean, 7) incompetent perforating veins per patient. Of the 832 patients undergoing SEPS, 460 (55%) underwent saphenous vein ligation and stripping at the same operation. In 92% ulcers healed or were significantly improved within 4 to 14 weeks. In 64 (8%) patients, ulcers failed to heal or there was no benefit from the operation. Thirty-two patients (4%) experienced recurrent ulceration or skin deterioration at 6 months-2 years (mean, 15 mo). Repeat SEPS was successful in 25 of these 96 patients, and deep valve repair was successful in 4 patients. In the 92 randomized patients with C4 disease, 41 refused postoperative AVP, leaving 51 compliant patients. The SEPS group (n = 25) had significantly reduced AVP (P <.01) compared with the control group (n = 26). Complications in 825 patients were less than 3% and consisted mostly of transient neurologic disorders (eg, paradysthesia), but deep venous thrombosis occurred in 2 patients, with pulmonary embolus in 1. No operative deaths occurred. Follow-up for 1 to 9 years (mean, 31/2 years) demonstrated durability.

CONCLUSION

The efficacy, safety, and durability of this operative protocol proved beneficial in our clinical experience with 832 patients during 9 years of follow-up. The SEPS subset of randomized patients with C4 disease experienced significant decrease in AVP, objectively supporting the effectiveness of reflux surgery in advanced CVI. Until definitive level I evidence is available, this operative technique is advocated as optimal therapy for CVI.

The impact of duplex scanning in phlebology

Chronic venous disease (CVD) is a tremendous medical and economic burden on society. In the past two decades the use of duplex ultrasound has emerged as the diagnostic method of choice for the diagnosis and management of CVD. In this article, we describe the specific techniques used in the assessment of the superficial, perforating, and deep venous systems. We also discuss the methods of ulcer bed and chronic obstruction evaluation. The contributions of the duplex ultrasound to the understanding of the pathophysiology and improvement of treatments for chronic venous disease are reviewed.