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Kienzl P, Deinsberger J, Weber B. Chronic Venous Disease: Pathophysiological Aspects, Risk Factors, and Diagnosis. Hamostaseologie 2024. [PMID: 38991541 DOI: 10.1055/a-2315-6206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024] Open
Abstract
Chronic venous disease (CVD) is highly prevalent in the general population and encompasses a range of pathological and hemodynamic changes in the veins of the lower extremities. These alterations give rise to a variety of symptoms, with more severe forms resulting in venous ulceration, which causes morbidity and high socioeconomic burden. The origins and underlying mechanisms of CVD are intricate and multifaceted, involving environmental factors, genetics, hormonal factors, and immunological factors that bring about structural and functional alterations in the venous system. This review offers the latest insights into the epidemiology, pathophysiology, and risk factors of CVD, aiming to provide a comprehensive overview of the current state of knowledge. Furthermore, the diagnostic approach for CVD is highlighted and current diagnostic tools are described.
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Affiliation(s)
- Philip Kienzl
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Benedikt Weber
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
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Vayssettes-Courchay C. A review of methodologies evaluating superficial vein properties in viv: focus on compliance and reactivity. INT ANGIOL 2021; 40:368-380. [PMID: 34236151 DOI: 10.23736/s0392-9590.21.04657-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The saphenous vein (SV) is a hindlimb superficial vein which has aroused a considerable interest because of its implication in chronic venous disease and its use in coronary artery or lower limb bypass grafts. The morphology and patency of the SV are commonly assessed for diagnosis and management, but the dynamic properties of the vein - compliance, elasticity and reactivity, less widely studied, are also fundamental issues. The subject of this review is neither to review the pathologies, nor the treatments or surgical procedures. The goal is to gather together all existing types of investigation on the superficial vein and to focus on the dynamic venous properties in vivo. The data collected indicate that plethysmography (PG) and ultrasound (US) are extensively used to evaluate SV patency, reflux and morphology. Their use to evaluate superficial vein compliance is less widespread but highly necessary. The protocols used via venous occlusion are described and the various parameters used to accurately measure compliance and distensibility versus elasticity are presented and discussed. The advantage of US diameter measurement is shown, including additional pulsatile compliance evaluation. The overview of venous reactivity greatly differs, being poorly studied in vivo, mainly by optical methods in humans or US echotracking in animals. Existing methodologies are potent but could be certainly developed and improved further for better characterization of the SV in human and for investigations of new devices, surgical techniques and pharmacological treatment in preclinical animal studies.
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Comparison of hand-held acoustic Doppler with point-of-care portable color Doppler ultrasound in the assessment of venous reflux disease. J Vasc Surg Venous Lymphat Disord 2020; 8:831-839.e2. [PMID: 32184080 DOI: 10.1016/j.jvsv.2019.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 11/23/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Diagnostic-quality portable color Doppler ultrasound (PCD) offers convenient point-of-care venous reflux disease (VRD) diagnosis. Philips Lumify (Philips N.V., Best, The Netherlands), a high-fidelity broadband linear array transducer (4-12 MHz frequency), connects through a web-enabled smartphone or tablet to cloud software and offers B-mode and color Doppler imaging without pulsed wave Doppler capability. The aims of the study were to compare hand-held acoustic Doppler (HHD) vs PCD diagnostic performance using conventional duplex ultrasound (DUP) as the "gold standard" for VRD assessment, to assess effects of body mass index (BMI) and disease severity on diagnostic performance of HHD and PCD, and to determine whether PCD offers any diagnostic improvement over HHD in VRD assessment. METHODS There were 241 patients (65 male, 176 female; mean age, 55.5 ± 15.5 years; mean BMI, 32.2 ± 7.9 kg/m2). DUP (447 legs), PCD (262 legs), and HHD (217 legs) studied the great saphenous vein at above-knee (AK) and below-knee (BK) levels. A phlebologist performed HHD, whereas PCD and DUP were performed sequentially (PCD first) by an experienced technologist and interpreted independently. PCD was done blinded to DUP results. DUP findings were analyzed blinded to HHD and PCD results. Venous reflux was dichotomously assessed as <2 seconds and >2 seconds. RESULTS HHD improves from moderate to good sensitivity from AK level (68%) to BK level (94%) but suffers poor specificity that declines significantly from AK level (50%) to BK level (12%; P < .05). HHD positive predictive value exceeds its negative predictive value (NPV) and remains unchanged from AK level (71%) to BK level (72%). HHD NPV remains consistently poor at AK (48%) and BK (42%) levels. PCD has similar sensitivity from AK level (69%) to BK level (74%), better AK level (79%) vs BK level (58%) specificity (P < .05), similar positive predictive value for AK (76%) and BK levels (78%), and better NPV for AK level (72%) vs BK level (53%; P < .05). BMI range (<30 kg/m2 vs ≥ 30 kg/m2) did not influence diagnostic performance of HHD and PCD significantly. HHD and PCD specificity was higher for Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class <4 compared with CEAP class ≥4 (P < .05). CONCLUSIONS The relative diagnostic performance of HHD and PCD is highly dependent on insonation level. PCD advantages compared with HHD are marginally greater specificity at AK and BK levels and better NPV at AK level. Compared with HHD, PCD's disadvantage is lower sensitivity at BK level. Both HHD and PCD have higher specificity at AK level than at BK level. Overall, PCD offers only moderate sensitivity and specificity, making it inadequate for exclusion of significant venous reflux. Neither obesity nor CEAP class significantly influenced the general diagnostic performance of PCD or HHD.
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Santler B, Goerge T. Die chronische venöse Insuffizienz - Eine Zusammenfassung der Pathophysiologie, Diagnostik und Therapie. J Dtsch Dermatol Ges 2018; 15:538-557. [PMID: 28485867 DOI: 10.1111/ddg.13242_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/11/2017] [Indexed: 01/06/2023]
Abstract
Die chronische Venenerkrankung ist eine weit verbreitete Krankheit, die in späteren Stadien mit einer Vielzahl an Symptomen, aber auch Komplikationen wie dem Ulcus cruris, einhergeht. Dies wiederum hat weitreichende Auswirkungen auf die Lebensqualität der Patienten wie auch auf das Gesundheitssystem. Für die Diagnostik der chronischen Venenerkrankungen steht eine Auswahl an Verfahren zur Verfügung, wobei sich die farbkodierte Duplexsonographie als Goldstandard etabliert hat. Im Bereich der Therapie kam es in den letzten Jahrzehnten zu großen Fortschritten, sodass heute auch Alternativen zum klassischen Stripping durch die endoluminalen Verfahren zur Verfügung stehen. Die Wahl der Therapieoption ist jedoch weiterhin stark abhängig von mehreren Faktoren, unter anderem von den anatomischen Gegebenheiten und dem Krankheitsstadium. Im folgenden Artikel werden die Anatomie und Pathophysiologie, sowie die aktuellen Standards der Diagnostik und Therapie zusammengefasst.
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Affiliation(s)
- Bettina Santler
- Klinik für Hautkrankheiten - Allgemeine Dermatologie und Venerologie, Universitätsklinikum Münster
| | - Tobias Goerge
- Klinik für Hautkrankheiten - Allgemeine Dermatologie und Venerologie, Universitätsklinikum Münster
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Santler B, Goerge T. Chronic venous insufficiency - a review of pathophysiology, diagnosis, and treatment. J Dtsch Dermatol Ges 2018; 15:538-556. [PMID: 28485865 DOI: 10.1111/ddg.13242] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/11/2017] [Indexed: 01/20/2023]
Abstract
Chronic venous disease is a common disorder associated with a variety of symptoms in later disease stages but also with complications such as venous leg ulcer. This, in turn, has substantial socioeconomic effects and significantly impacts patients' quality of life. While there are a number of diagnostic procedures available, color-flow duplex ultrasound has become the gold standard. As regards therapeutic options, major advances have been made in recent decades. Today, there are alternatives to saphenofemoral ligation and stripping of the great saphenous vein, including endovenous thermal ablation techniques. However, treatment selection continues to depend on many factors such as individual anatomical circumstances and disease stage. The following article provides an overview of the anatomy and pathophysiology as well as current diagnostic and therapeutic standards.
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Affiliation(s)
- Bettina Santler
- Department of Dermatology and Venereology, University Hospital Münster, Münster, Germany
| | - Tobias Goerge
- Department of Dermatology and Venereology, University Hospital Münster, Münster, Germany
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Evidence-based (S3) guidelines for diagnostics and treatment of venous leg ulcers. J Eur Acad Dermatol Venereol 2016; 30:1843-1875. [PMID: 27558268 DOI: 10.1111/jdv.13848] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 06/17/2016] [Indexed: 11/29/2022]
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Chapter 2 - Diagnostics. J Eur Acad Dermatol Venereol 2016. [PMID: 27558780 DOI: 10.1111/jdv.3_13848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Somjen GM, Donlan J, Hurse J, Bartholomew J, Johnston AH, Royle JP. Venous Reflux at the Sapheno-Femoral Junction. Phlebology 2016. [DOI: 10.1177/026835559501000402] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: To clarify reflux patterns in the sapheno-femoral junction in legs with varicose veins that display incompetence in the proximal long saphenous vein on duplex scan examination. Patients and method: One hundred consecutive extremities were selected for ultrasound studies. Venous reflux was examined in the common femoral vein and long saphenous vein at five selected levels in the vicinity of the sapheno-femoral junction. Results: Duplex ultrasound examination confirmed that in 44 extremities reflux was detectable both in the long saphenous vein and common femoral vein indicating ‘true’ sapheno-femoral incompetence. In 56 legs reflux was limited to the long saphenous vein, whilst the first saphenous valve remained competent. The ultrasound examination suggested that in these cases the reflux originated from the numerous tributaries of the proximal long saphenous vein. Conclusion: Our findings emphasize the transfascial escape (reflux from the deep veins) is not a necessary precondition of long saphenous vein incompetence and related varicose veins.
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Affiliation(s)
- G. M. Somjen
- The Vascular Centre and Vascular Surgery Unit, Mornington Peninsula Hospital, Frankston, Australia
| | - J. Donlan
- The Vascular Centre and Vascular Surgery Unit, Mornington Peninsula Hospital, Frankston, Australia
| | - J. Hurse
- The Vascular Centre and Vascular Surgery Unit, Mornington Peninsula Hospital, Frankston, Australia
| | - J. Bartholomew
- The Vascular Centre and Vascular Surgery Unit, Mornington Peninsula Hospital, Frankston, Australia
| | - A. H. Johnston
- The Vascular Centre and Vascular Surgery Unit, Mornington Peninsula Hospital, Frankston, Australia
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Evans CJ, Leng GC, Stonebridge P, Lee AJ, Allan PL, Fowkes FGR. Reproducibility of Duplex Ultrasound in the Measurement of Venous Reflux. Phlebology 2016. [DOI: 10.1177/026835559501000405] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To determine the reproducibility of duplex ultrasound in the measurement of reflux duration in lower limb veins. Design: Repeatability study. Setting: Vascular clinic in a tertiary referral centre. Participants: Twenty-one patients with severe venous disease. Interventions: Patients were scanned using duplex ultrasound by two of three observers, then rescanned by a different pair of observers after a mean interval of 51 days. Main outcome measures: Duration of venous reflux. Results: On a Wilcoxon signed rank test, observers 2 and 3 showed no significant interobserver variability. The other pairs of observers agreed at the majority of segments, but differed at the popliteal vein ( p≤0.001), and superficial femoral and common femoral veins ( p≤0.05). Observer 2 showed no significant intraobserver variability, but observer 1 differed at the common femoral and superficial femoral veins ( p≤0.05), and observer 3 differed at the short saphenous vein ( p≤0.05). Conclusions: Reproducibility was reasonable at certain sites, but appeared to be influenced by position of the vein.
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Affiliation(s)
- C. J. Evans
- Wolfson Unit for Prevention of Peripheral Vascular Diseases, Medical School, University of Edinburgh, Edinburgh
| | - G. C. Leng
- Wolfson Unit for Prevention of Peripheral Vascular Diseases, Medical School, University of Edinburgh, Edinburgh
| | | | - A. J. Lee
- Wolfson Unit for Prevention of Peripheral Vascular Diseases, Medical School, University of Edinburgh, Edinburgh
| | | | - F. G. R. Fowkes
- Wolfson Unit for Prevention of Peripheral Vascular Diseases, Medical School, University of Edinburgh, Edinburgh
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Abstract
Objective: To identify the current practice of surgeons and variations between these surgeons in the investigation and treatment of varicose veins. Design: Questionnaire submitted to all surgeons treating varicose veins. Setting: All general surgeons in the Northern Region of England. Results: The response was 83% with 60 surgeons (85% of responders) treating varicose veins. Thirty-five per cent have a vascular specialist interest and treat 58% of all the varicose veins; 37% of surgeons complement initial assessment by clinical examination with hand-held Doppler examination. For long saphenous vein incompetence all surgeons perform high saphenous ligation, with 67% stripping the vein to the knee and 23% to the ankle. For short saphenous incompetence, 28% localize the saphenopopliteal junction by investigation prior to treatment, 92% perform saphenopopliteal ligation and 13% strip the vein. Conclusions: The extent of investigation and the nature of treatment of varicose veins vary considerably between consultants. Relatively few surgeons use hand-held Doppler and surgeons remain divided on the use and extent of stripping of the saphenous veins.
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O'Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, Lurie F, Henke PK, Gloviczki ML, Eklöf BG, Stoughton J, Raju S, Shortell CK, Raffetto JD, Partsch H, Pounds LC, Cummings ME, Gillespie DL, McLafferty RB, Murad MH, Wakefield TW, Gloviczki P. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014; 60:3S-59S. [PMID: 24974070 DOI: 10.1016/j.jvs.2014.04.049] [Citation(s) in RCA: 377] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, Lohr JM, McLafferty RB, Meissner MH, Murad MH, Padberg FT, Pappas PJ, Passman MA, Raffetto JD, Vasquez MA, Wakefield TW. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53:2S-48S. [PMID: 21536172 DOI: 10.1016/j.jvs.2011.01.079] [Citation(s) in RCA: 826] [Impact Index Per Article: 63.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 01/12/2011] [Accepted: 01/15/2011] [Indexed: 12/20/2022]
Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Noppeney T, Kluess H, Breu F, Ehresmann U, Gerlach H, Hermanns HJ, Nüllen H, Pannier F, Salzmann G, Schimmelpfennig L, Schmedt CG, Steckmeier B, Stenger D. Leitlinie zur Diagnostik und Therapie der Krampfadererkrankung. GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00772-010-0842-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Meissner MH, Moneta G, Burnand K, Gloviczki P, Lohr JM, Lurie F, Mattos MA, McLafferty RB, Mozes G, Rutherford RB, Padberg F, Sumner DS. The hemodynamics and diagnosis of venous disease. J Vasc Surg 2007; 46 Suppl S:4S-24S. [PMID: 18068561 DOI: 10.1016/j.jvs.2007.09.043] [Citation(s) in RCA: 192] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2006] [Accepted: 08/23/2007] [Indexed: 01/19/2023]
Affiliation(s)
- Mark H Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle 98195, USA.
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Secchi F, Miyamotto M, França GJ, Oliveira AD, Vidal EA, Timi JRR, Moreira RCR. Prevalência do refluxo na veia safena parva em varizes primárias não complicadas dos membros inferiores pelo eco-Doppler colorido. J Vasc Bras 2006. [DOI: 10.1590/s1677-54492006000100009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Determinar a prevalência de refluxo venoso na veia safena parva em membros inferiores com varizes primárias não complicadas pelo eco-Doppler colorido. MÉTODO: No período de 18 meses, 1.953 pacientes foram submetidos ao eco-Doppler colorido de membros inferiores por doença venosa. Destes, 1.631 com varizes primárias não complicadas foram selecionados para esta análise, sendo que 1.383 eram do sexo feminino (84,79%) e 248 (15,21%) do sexo masculino. A média de idade dos pacientes foi de 42,89 (± 0,48) anos, variando de 13 a 85 anos. Dos 1.631 pacientes, 1.323 foram submetidos a exame bilateral e 308 a exame unilateral, totalizando 2.954 membros inferiores com varizes primárias não complicadas avaliados. Desse total, 1.461 eram membros inferiores direitos e 1.493, esquerdos. Todos os exames foram realizados seguindo o mesmo protocolo. RESULTADO: Dos 2.954 membros inferiores avaliados, 372 (12,59%) apresentaram refluxo em veia safena parva. A prevalência nos homens foi de 14,08% e, nas mulheres, de 12,35%. O refluxo da safena parva foi maior no membro inferior esquerdo (13.13%) do que no direito (12,05%). A prevalência do refluxo foi significativamente maior nos pacientes acima de 60 anos. CONCLUSÃO: O refluxo da veia safena parva é relativamente comum, e sua pesquisa deve ser sempre realizada em pacientes com varizes primárias de membros inferiores.
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Campbell WB, Niblett PG, Peters AS, MacIntyre JB, Sherriff S, Palfreyman S, Michaels JA. The Clinical Effectiveness of Hand Held Doppler Examination for Diagnosis of Reflux in Patients with Varicose Veins. Eur J Vasc Endovasc Surg 2005; 30:664-9. [PMID: 16385703 DOI: 10.1016/j.ejvs.2005.05.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the accuracy of hand held Doppler (HHD) as a rapid screening test for selecting varicose vein patients for duplex imaging. DESIGN Prospective single blind study of consecutive patients in a randomised trial. MATERIALS Use of hand held Doppler and duplex ultrasound scanners. METHODS One thousand two hundred and eighteen legs (943 patients) were examined by HHD and then duplex. HHD examiners recorded whether they would normally have requested duplex. RESULTS HHD results of one Clinical Assistant (166 limbs) were significantly poorer than all others and his results were excluded from analysis. Duplex would not have been requested in 645 of 1052 (62%) limbs. Among these HHD missed significant reflux in the long saphenous vein in 18 (3%) and the short saphenous in 25 (4%). Reasons for requesting duplex were popliteal fossa reflux (202); recurrent (94) or atypical (86) varicose veins; and possible previous thrombosis (67). Differences were observed between staff and units in requests for duplex; and in thoroughness and style of duplex reporting. CONCLUSIONS Selective use of HHD can avoid duplex imaging for many patients, with a low failure rate for detecting correctable venous reflux. Observed variations between individuals and units in results of HHD and duplex imaging have implications for the increasing use of duplex by clinicians.
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Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg 2005; 31:83-92. [PMID: 16226898 DOI: 10.1016/j.ejvs.2005.07.019] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2005] [Accepted: 07/05/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP). The aim was to obtain a consensus of international experts on the methodology to be used for assessment of veins in the lower limb by ultrasound imaging. DESIGN Consensus conference leading to a consensus document. METHODS The authors invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the experts were made available to all participants via the UIP website. The authors prepared a draft document for discussion at a UIP Chapter meeting held in San Diego, USA in August 2003. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually all participants agreed the final version of the paper. RESULTS The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document suggests a methodology for complete assessment of the superficial and perforating veins of the lower limbs, including recommendations on reporting results and training of personnel involved in these investigations. CONCLUSIONS The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs venous system by duplex ultrasonographpy.
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Min RJ, Khilnani NM, Golia P. Duplex ultrasound evaluation of lower extremity venous insufficiency. J Vasc Interv Radiol 2004; 14:1233-41. [PMID: 14551269 DOI: 10.1097/01.rvi.0000092663.72261.37] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Physicians unfamiliar with venous insufficiency, particularly disorders of the superficial venous system, often underestimate the complexity of the problem and the importance of proper evaluation before initiating treatment. In addition to a directed history evaluation and physical examination, additional evaluation with use of a variety of noninvasive diagnostic instruments, including duplex ultrasound, may be necessary when determining the cause, severity, and best treatment options available for a particular patient. After such evaluation, the treating physician should have a precise map of the patient's pathways of venous insufficiency, including sources of reflux (eg, saphenofemoral junction, saphenopopliteal junction, perforators), tributaries, vein size, and vein morphology.
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Affiliation(s)
- Robert J Min
- Cornell Vascular, Weill Medical College of Cornell University, 416 East 55th Street, New York, New York 10022, USA.
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Smith JJ, Brown L, Greenhalgh RM, Davies AH. Randomised trial of pre-operative colour duplex marking in primary varicose vein surgery: outcome is not improved. Eur J Vasc Endovasc Surg 2002; 23:336-43. [PMID: 11991696 DOI: 10.1053/ejvs.2002.1607] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE the ability of colour duplex to accurately locate incompetent venous sites has been widely published; its value in pre-operative marking in simple primary varicose vein surgery is evaluated in this study. DESIGN OF STUDY prospective randomised controlled trial. SETTING regional vascular service, hospital patients. SUBJECTS consecutive patients (149) undergoing primary varicose vein surgery where the only difference was one group of patients received duplex marking prior to surgery. Six weeks and 12 months post-operatively all patients had a colour duplex scan to determine the accuracy of surgery and the presence of residual/recurrent varicose veins and completed the Aberdeen, SF-36, and EuroQol quality of life questionnaires. INTERVENTIONS varicose vein surgery. MAIN OUTCOME MEASURES Duplex evidence of venous incompetence, quality of life measures using the SF-36 and Aberdeen Varicose Veins Questionnaire. RESULTS pre-operative marking of primary varicose veins by skilled duplex ultrasonography does not improve the accuracy or recurrence rate following surgery. Quality of life improved significantly following surgery in both groups, however there was no difference in this improvement between the groups. CONCLUSION the trial has not demonstrated any additional benefit of pre-operative colour duplex marking over that of clinical and hand held Doppler marking in terms of satisfactory varicose vein surgery performance at 6 weeks or 12 months in patients with primary varicose veins of the long saphenous system. It role in the short saphenous system is less clear.
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Affiliation(s)
- J J Smith
- Department of Vascular Surgery, Imperial College of Science, Technology and Medicine, Charing Cross Hospital, London, UK
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Abstract
Aim: To review the investigations which are performed in patients presenting with varicose veins prior to treatment. Method: A review of current literature in the field of the investigation of venous disease of the lower limb has been conducted using MedLine. Synthesis: Continuous wave (CW) Doppler is effective in detecting venous reflux in the sapheno-femoral junction and the long saphenous vein. In the popliteal fossa, for perforating veins and for the deep veins this technique has reduced accuracy. Duplex ultrasonography is widely used in the management of venous disease of the lower limb. This investigation provides reliable anatomical information but limited functional data about the veins. Phlebography and varicography are effective investigations but are being replaced by duplex ultrasonography. Plethysmographic tests assess venous function but are poor at anatomical identification of the problem. They may be used in the monitoring of venous function during treatment and in identifying the contribution of superficial venous reflux in patients with combined deep and superficial venous disease. Conclusion: Clinical examination is no longer sufficient to assess patients with venous disease of the lower limb prior to surgery. CW Doppler is the minimum investigation but duplex ultrasonography is the most effective non-invasive investigation. Plethysmographic tests have limited application in the management of varicose veins.
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Abstract
This consensus document provides an up-to-date account of the various methods available for the investigation of chronic venous insufficiency of the lower limbs (CVI), with an outline of their history, usefulness, and limitations. CVI is characterized by symptoms or signs produced by venous hypertension as a result of structural or functional abnormalities of veins. The most frequent causes of CVI are primary abnormalities of the venous wall and the valves and secondary changes due to previous venous thrombosis that can lead to reflux, obstruction, or both. Because the history and clinical examination will not always indicate the nature and extent of the underlying abnormality (anatomic extent, pathology, and cause), a number of diagnostic investigations have been developed that can elucidate whether there is calf muscle pump dysfunction and determine the anatomic extent and severity of obstruction or reflux. The difficulty in deciding which investigations to use and how to interpret the results has stimulated the development of this consensus document. The aim of this document was to provide an account of these tests, with an outline of their usefulness and limitations and indications of which patients should be subjected to the tests and when and of what clinical decisions can be made. This document was written primarily for the clinician who would like to learn the latest approaches to the investigation of patients with CVI and the new applications that have emerged from recent research, as well as for the novice who is embarking on venous research. Care has been taken to indicate which methods have entered the clinical arena and which are mainly used for research. The foundation for this consensus document was laid by the faculty at a meeting held under the auspices of the American Venous Forum, the Cardiovascular Disease Educational and Research Trust, the European Society of Vascular Surgery, the International Angiology Scientific Activity Congress Organization, the International Union of Angiology, and the Union Internationale de Phlebologie at the Abbaye des Vaux de Cernay, France, on March 5 to 9, 1997. Subsequent input by co-opted faculty members and revisions in 1998 and 1999 have ensured a document that provides an up-to-date account of the various methods available for the investigation of CVI.
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Affiliation(s)
- A N Nicolaides
- Irvine Laboratory for Cardiovascular Investigation and Research, Department of Vascular Surgery, Imperial College School of Medicine (St Mary's Campus), London W2 1NY, UK.
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Darke SG, Vetrivel S, Foy DM, Smith S, Baker S. A comparison of duplex scanning and continuous wave Doppler in the assessment of primary and uncomplicated varicose veins. Eur J Vasc Endovasc Surg 1997; 14:457-61. [PMID: 9467520 DOI: 10.1016/s1078-5884(97)80124-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To compare the findings of continuous wave Doppler (CWD) with duplex ultrasound in the assessment of primary and uncomplicated varicose veins, and to determine how their relative roles might be best applied. MATERIALS AND METHODS One hundred consecutive limbs were studied in 73 patients with primary (no previous surgery) and uncomplicated (no significant skin change) varicose veins. CWD was employed by a single observer; followed by duplex scanning performed "blind" and independently. RESULTS There were 87 limbs with long saphenous incompetence on duplex; all but four of which were correctly identified by CWD, by which technique there were no false positives. (Sensitivity 95%, specificity 100%.) There were 21 limbs with short saphenous incompetence on duplex, all but two of which were recognised on CWD. However, CWD incorrectly diagnosed reflux at the saphenopopliteal junction in five limbs (false positives) with what was, in fact, segmental reflux in the long saphenous trunk on duplex (sensitivity 90%, specificity 93%.) This would have led to inappropriate exploration of the saphenopopliteal junction had surgery proceeded without checking with duplex. CONCLUSIONS CWD is adequate for long saphenous incompetence. All "reflux" demonstrated on CWD in the popliteal fossa (about 25% of cases) should be checked by duplex. If this policy had been followed, all the patients in this study would have undergone the correct procedure. The only "errors" would have been missing coexistent short saphenous incompetence in two limbs undergoing appropriate long saphenous exploration.
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Affiliation(s)
- S G Darke
- Department of Vascular Surgery, Royal Bournemouth Hospital, U.K
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Campbell WB, Niblett PG, Ridler BMF, Peters AS, Thompson JF. Hand-held Doppler as a screening test in primary varicose veins. Br J Surg 1997. [DOI: 10.1002/bjs.1800841113] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pierik EG, Toonder IM, van Urk H, Wittens CH. Validation of duplex ultrasonography in detecting competent and incompetent perforating veins in patients with venous ulceration of the lower leg. J Vasc Surg 1997; 26:49-52. [PMID: 9240321 DOI: 10.1016/s0741-5214(97)70146-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Incompetent perforating veins play an important role in the etiologic mechanism of venous ulceration and recurrent varicose veins. The anatomic and functional status of the venous system can be evaluated by duplex ultrasonography. To determine the value of this technique in the identification of competent and incompetent perforating veins, a prospective study was performed. METHODS In patients who underwent subfascial exploration for venous ulceration of the lower leg, the preoperative findings of duplex ultrasonography were compared with the findings at surgical exploration. RESULTS In 20 consecutive patients, 42 incompetent and 8 competent perforating veins were detected by duplex ultrasonography. During operation the location of all 50 perforating veins appeared to be predicted correctly. Eleven additional perforating veins that had not been detected by duplex ultrasonography were found during operation. The sensitivity and specificity of duplex ultrasonography in predicting the site of perforating veins at the medial side of the lower leg in our study were 79.2% and 100%, respectively, for incompetent perforating veins and 82% and 100%, respectively, for competent and incompetent perforating veins. CONCLUSION These figures indicate that duplex-guided local exploration of the lower leg in patients with venous ulceration as a result of incompetent perforating veins would miss a substantial number of perforating veins, possibly leading to incomplete healing or recurrent ulceration.
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Affiliation(s)
- E G Pierik
- Department of Surgery, Sint Franciscus Gasthuis, Rotterdam, The Netherlands
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26
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Cheng SW, Wong J. Chronic venous insufficiency in a Chinese population: an anatomic and functional study by continuous-wave Doppler and photoplethysmography. Ann Vasc Surg 1995; 9:274-9. [PMID: 7632556 DOI: 10.1007/bf02135287] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A total of 1583 limbs in 878 patients who presented with symptoms of chronic venous insufficiency of the lower limbs were examined in the vascular laboratory. The anatomic distribution of valvular insufficiency was determined by continuous-wave Doppler ultrasound and functional severity was determined by the venous refilling time (VRT) using photoplethysmography. Severity of reflux was assessed using a four-class grading scale (classes 0 to 3) based on clinical and VRT criteria. A mixed incompetence of the valves in the superficial system and the perforators was encountered in the majority of patients (44% in class 0 and 85% in class 3). Deep vein incompetence was less common and usually consisted of isolated proximal incompetence of the common femoral vein (up to 32% in class 3) or was of a mixed type (21% in class 3). Isolated distal deep vein incompetence was uncommon. Proximal femoral vein incompetence and superficial system incompetence at the saphenofemoral junction were associated with severe reflux. There was significant improvement in the VRT in patients with more severe reflux (class 2 or 3) after application of an ankle tourniquet. Symptoms of moderate to severe chronic venous insufficiency and ankle ulceration may be a result of long-standing superficial system incompetence rather than deep venous disease and may thus be amendable to simple saphenofemoral ligation and interruption of perforators.
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Affiliation(s)
- S W Cheng
- Department of Surgery, University of Hong Kong
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Abstract
BACKGROUND A number of informative and detailed scientific communications have been published in recent years on the functional anatomy of the lower extremity venous system. OBJECTIVE This paper is aimed at providing basic anatomic information for physicians interested in phlebology. It also highlights the new research areas and the changing concepts on the the pathophysiology of varicose veins. METHODS The material is concentrated on observations made during duplex scan examination of the venous drainage of normal and abnormal limbs. RESULTS The etiology and classification of varicose veins are discussed, followed by a description of the subcutaneous venous anatomy based upon ultrasound studies. The anatomy of venous reflux in different segments of the superficial venous system is examined in the light of recent duplex ultrasound findings. CONCLUSION The presentation and treatment of varicose veins may vary depending on the anatomical distribution of valvular incompetence.
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Affiliation(s)
- G M Somjen
- Frankston Vascular and Cardiac Centre, Mornington Peninsula Hospital, Victoria, Australia
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Redwood NF, Lambert D. Patterns of reflux in recurrent varicose veins assessed by duplex scanning. Br J Surg 1994; 81:1450-1. [PMID: 7820467 DOI: 10.1002/bjs.1800811014] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- N F Redwood
- University Department of Surgery, Medical School, Newcastle upon Tyne, UK
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Goldman MP, Weiss RA, Bergan JJ. Diagnosis and treatment of varicose veins: a review. J Am Acad Dermatol 1994; 31:393-413; quiz 414-6. [PMID: 8077464 DOI: 10.1016/s0190-9622(94)70202-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Varicose veins are superficial vessels that are abnormally twisted, lengthened, or dilated and are usually caused by inefficient or defective valves within the vein. They represent a medical condition accompanied by symptoms deserving treatment. Varicose veins are a manifestation of venous disease that may precede later severe complications. Varicosities cause cutaneous disease in addition to complications specific to the venous system. This article reviews the epidemiology, adverse sequelae, anatomy, pathophysiology, evaluation, and treatment of varicose veins.
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Affiliation(s)
- M P Goldman
- Dermatology Associates of San Diego County, Inc, California
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