Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial

BACKGROUND

Chronic venous leg ulceration can be managed by compression treatment, elevation of the leg, and exercise. The addition of ablative superficial venous surgery to this strategy has not been shown to affect ulcer healing, but does reduce ulcer recurrence. We aimed to assess healing and recurrence rates after treatment with compression with or without surgery in people with leg ulceration.

METHODS

We did venous duplex imaging of ulcerated or recently healed legs in 500 consecutive patients from three centres. We randomly allocated those with isolated superficial venous reflux and mixed superficial and deep reflux either compression treatment alone or in combination with superficial venous surgery. Compression consisted of multilayer compression bandaging every week until healing then class 2 below-knee stockings. Primary endpoints were 24-week healing rates and 12-month recurrence rates. Analysis was by intention to treat.

FINDINGS

40 patients were lost to follow-up and were censored. Overall 24-week healing rates were similar in the compression and surgery and compression alone groups (65% vs 65%, hazard 0.84 [95% CI 0.77 to 1.24]; p=0.85) but 12-month ulcer recurrence rates were significantly reduced in the compression and surgery group (12% vs 28%, hazard -2.76 [95% CI -1.78 to -4.27]; p<0.0001). Adverse events were minimal and about equal in each group.

INTERPRETATION

Surgical correction of superficial venous reflux reduces 12-month ulcer recurrence. Most patients with chronic venous ulceration will benefit from the addition of simple venous surgery.

Structured exercise improves calf muscle pump function in chronic venous insufficiency: a randomized trial

OBJECTIVE

Deterioration of calf muscle pump function is associated with progression of chronic venous insufficiency (CVI). We postulated that a supervised exercise program would improve calf muscle strength and venous hemodynamics in patients with CVI.

METHODS

We recruited 31 patients for this randomized, prospective trial. Inclusion criteria required the presence of skin changes or ulceration (CEAP 4, 5, 6), and duplex ultrasound scanning (reflux or scarring) and air plethysmographic (APG) evidence of CVI. Subjects were randomized into control (n = 13) and therapy (n = 18) groups. Class II (30-40 mm Hg) compression hosiery was given to all. The experimental group received physical therapy designed specifically to strengthen calf musculature. Dynamic strength and power were measured with a Biodex II dynamometer (Biodex Medical Systems, Shirley, NY) at slow and fast speeds. Reflux (venous filling index) and calf pump function (ejection fraction, residual volume fraction) were measured with APG. Quality-of-life questionnaires and venous severity scores were also administered. Outcomes were compared 6 months after initiation of exercise. Probability of treatment effect was tested with univariate analysis of variance, with control for baseline values.

RESULTS

Demographic variables and medical comorbidities were not different between groups. After 6 months of intervention, indicators of calf pump function returned to a normal range in the therapy (experimental) group. Mean residual volume fraction was improved in the exercise group (-8.75 +/- 4.6 vs 3.4 +/- 2.9 in the control group; P <.029). Mean ejection fraction was increased in the exercise group (3.48 +/- 2.7 vs -1.4 +/- 2.1 in the control group; P <.026). Reflux, while substantially greater than the normal value of 2.0 mL/s in both groups, was unchanged. The exercise regimen improved isokinetic peak torque/body weight at both slow speed (3.1 +/- 1.4 in the therapy group vs -1.0 +/- 1.1 in the control group; P <.05) and fast speed (2.8 +/- 0.9 in the therapy group vs - 0.3 +/- 0.6 in the control group; P <.03). No changes were observed in quality-of-life or severity scores.

CONCLUSIONS

Calf muscle pump function and dynamic calf muscle strength were improved after a 6-month program of structured exercise. Directed physical conditioning of the calf musculature may prove beneficial for patients with or without alternative management options for severe CVI. Further research on exercise for patients with CVI is warranted.

Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency

BACKGROUND

Endovascular radiofrequency obliteration has been used as an alternative to conventional vein-stripping surgery for elimination of saphenous vein insufficiency. A clinical registry was established in 1998, and its mid-term results have been reported previously. This study is to demonstrate the long-term treatment outcomes and to determine the risk factors that affect treatment efficacy.

METHODS

Data were collected in an ongoing multicenter, prospective registry. Patients were treated before October 2004. Clinical and duplex ultrasound follow-up was performed 1 week, 6 months, 1 year, and yearly thereafter to 5 years. Treatment efficacy and clinical improvement after the procedure were analyzed. Three types of anatomical failure were identified. Logistic regression analysis was performed to determine the existence of any significant risk factors associated with anatomical failure. Risk factors considered were age, gender, body mass index, vein diameter, and pullback speed. The impact of anatomical failure on clinical symptoms and varicose vein recurrence was also analyzed.

RESULTS

There were 1,006 patients (1,222 limbs) treated, their mean age was 47.4 +/- 12.1 years, and 78.1% were female. Veins treated included 89.1% great saphenous vein above-knee segments, 1.2% great saphenous vein below-knee segments, 4.1% great saphenous vein groin-to-ankle, 4.3% small saphenous veins, and 1.3% accessory saphenous veins. Mean vein diameter was 7.5 mm, with a maximum of 24 mm. Vein occlusion rates were 87.1%, 88.2%, 83.5%, 84.9%, and 87.2%, and reflux-free rates were 88.2%, 88.2%, 88.0%, 86.6%, and 83.8% at each annual follow-up. Clinical symptom improvement was seen in 70% to 80% of limbs with anatomical failures and in 85% to 94% of limbs with anatomical success from 6 months to 5 years after the radiofrequency obliteration. Logistic regression analysis showed that catheter pullback speed (P < .0001) and body mass index (P < .0333) were risk factors for anatomical failure. Limbs that had type II and type III anatomical failures were found to be more prone to varicose vein recurrence.

CONCLUSIONS

Endovascular radiofrequency obliteration of saphenous vein reflux exhibits enduring efficacy. Adequate pullback speed during the procedure should be emphasized to ensure the proper thermal dose delivery. A whole treatment strategy to address hemodynamically significant tributaries and perforators can further improve treatment outcomes. Body mass index is a risk factor for anatomical failure, indicating the impact of hemodynamic factors on disease progression and recurrence.

Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles

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.

Femoral venous reflux abolished by greater saphenous vein stripping

Preoperative venous duplex scanning has revealed unexpected deep venous incompetence in patients with apparently only varicose veins. Acting on the hypothesis that the deep vein reflux was secondary to deep vein dilation caused by reflux volume, the following was done. Between July 1990 and April 1993, 29 limbs in 21 patients (16 females) were examined by color-flow duplex imaging to determine valve closure by the method of van Bemmelen. Instrumentation included high-resolution ATL-9 venous interrogation using a pneumatic cuff deflation stimulus of reflux in the standing, nonweight-bearing limb. All limbs showed greater saphenous vein reflux. Twenty-nine showed superficial femoral vein reflux and of these three showed popliteal vein reflux. Duplex testing was performed by a certified vascular technologist whose interpretation was blinded as to the results of clinical examination and grading of the severity of venous insufficiency. Surgery was performed on an outpatient basis under general anesthesia using groin-to-knee removal of the greater saphenous vein by the vein inversion technique of Van Der Strict. Stab avulsion of varicose tributary veins was accomplished during the same period of anesthesia. In 27 of 29 limbs with preoperative femoral reflux, that reflux was abolished by greater saphenous stripping. In patients with popliteal reflux both femoral and popliteal reflux was abolished. Improvement of deep venous hemodynamics by ablation of superficial reflux supports the reflux circuit theory of venous overload. Furthermore, preoperative evaluation of venous hemodynamics by duplex scanning appears to provide useful pre- and postoperative information regarding venous insufficiency in individual patients.

Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency

OBJECTIVE

Although newer techniques to promote the healing of leg ulcers associated with chronic venous insufficiency are promising, improved healing rates and cost effectiveness are unproven. We prospectively followed a series of patients who underwent treatment with outpatient compression for venous stasis ulcers without adjuvant techniques to determine healing rates and costs of treatment.

METHODS

Two hundred fifty-two patients with clinical or duplex scan evidence of chronic venous insufficiency and active leg ulcers underwent treatment with ambulatory compression techniques. The patients were prospectively followed with wound measurements at 1-week to 2-week intervals, and the factors that were associated with delayed healing were determined.

RESULTS

Of all the ulcers, 57% were healed at 10 weeks of treatment and 75% were healed at 16 weeks. Ultimately, 96% of the ulcers healed, and only 1 major amputation was necessitated (0.4%). Initial ulcer size and moderate arterial insufficiency (ankle brachial index, 0.5 to 0.8; n = 34) were factors that were independently associated with delayed healing (P <.01). Patient age, ulcer duration before treatment, and morbid obesity did not significantly affect healing times. The cost of 10 weeks of outpatient treatment with compression techniques ranged from $1444 to $2711.

CONCLUSION

The treatment of venous stasis ulcers with compression techniques results in reliable, cost-effective healing in most patients. Current adjuvant techniques may prove to be useful but are likely to be cost effective only in a minority of cases, particularly in patients with large initial ulcer size or arterial insufficiency.

Long-term results of venous valve reconstruction: a four- to twenty-one-year follow-up

PURPOSE

The purpose of this study is to describe the very long-term clinical, hemodynamic, and imaging results of venous valve reconstruction for reflux disease in patients with chronic venous insufficiency.

METHODS

There were 51 extremities (48 patients) with follow-up of 4 to 21 years with a mean of 10.6 years. Clinical severity was graded as asymptomatic (class 0), mildly symptomatic (class 1), moderately symptomatic but without ulceration (class 2), or severely symptomatic with or without ulceration (class 3). Preoperative and postoperative evaluation consisted of history and physical examination, ascending venography (preoperative only), ambulatory venous pressures or photoplethysmography, and descending venography or duplex scanning.

RESULTS

Before surgery, 49 (96%) of 51 limbs demonstrated severe, class 3 disease, and two limbs were classified as class 2 disease. After venous valve reconstruction by either direct femoral vein valve repair, transposition, or transplantation, long-term clinical success of achieving a class 0 or 1 result (by life-table analysis) was 60% at 10 years. Thirty-three percent demonstrated a class 0 result in which the limbs were free from symptoms and had no need for long-term elastic support. After 6 years clinical results were stable and did not deteriorate. Incompetent perforators were identified in 31 cases and were treated selectively. Three disease patterns of chronic venous insufficiency were identified: primary valve insufficiency 43%, postthrombotic syndrome 31%, and a group consisting of both primary valve insufficiency of the superficial femoral vein and postthrombotic syndrome of the calf veins (primary valve insufficiency-postthrombotic syndrome) 26%. Ten-year cumulative clinical success was clearly superior in limbs with primary valve insufficiency corrected by valve repair (73%) as opposed to those with postthrombotic syndrome treated by either valve transposition or transplantation (43%) (p = 0.029). Clinical outcome correlated strongly with postoperative imaging results, and durability of valve repair was confirmed by demonstrating competence up to 16 years after the operation. Significant improvement in ambulatory venous pressure (mean percentage of pressure fall and refill time) was found in limbs with class 0 or 1 outcome; however, values did not reach "normal" levels in all cases. Recurrent ulcerations after the operation were attributed to failed reconstructions (10), incompetent profunda femoris veins (three), incompetent perforators (three), and concomitant lymphedema (one).

CONCLUSIONS

This report highlights a difference found in very long-term prognosis of surgical treatment of primary valve insufficiency as opposed to postthrombotic syndrome. Long-term elimination of symptoms of chronic venous insufficiency is achieved by valve repair for primary valve insufficiency beyond 10 years, whereas late results of treatment of postthrombotic syndrome in this study was accompanied by high recurrence rates and warrants further investigation.

Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein

This prospective randomized study compared the treatment of greater saphenous vein insufficiency by stripping and local avulsions of varicose veins with high ligation of the saphenofemoral junction (crossectomy) combined with sclerocompression therapy. Of 156 consecutive patients, 89 legs were randomly allocated to stripping and 92 to high ligation. At follow-up of 3 months and 1, 2, and 3 years after treatment, clinical and Doppler ultrasound results, and complaints and cosmetic results, as judged by the patient and the surgeon, were scored. At 3 years, 69 limbs in the stripping group (78%) and 73 limbs in the ligation group (79%) were available to follow-up. The cosmetic results, both judged by the patient and the surgeon, were significantly better (P < 0.05) in the stripped limbs than in the limbs with high ligation and sclerotherapy. Clinical and Doppler ultrasound evidence of reverse flow in the saphenous vein was significantly less (P < 0.001) after the stripping operation. The results of treatment of isolated saphenous vein insufficiency by stripping operation, therefore, were superior to those obtained by high ligation combined with sclerotherapy.

Greater Energy Delivery Improves Treatment Success of Endovenous Laser Treatment of Incompetent Saphenous Veins

PURPOSE

Early and midterm results of endovenous laser treatment (EVLT) of the saphenous veins for the treatment of symptomatic insufficiency are promising. However, technical factors contributing to success or failure of saphenous vein EVLT have not been fully investigated. This study was performed to test the hypothesis that treatment success is related to achieving a critical threshold of energy delivery relative to the length of vein treated.

MATERIALS AND METHODS

Data regarding length of treated vein and total energy delivered were collected from prospectively acquired databases at two institutions. Ultrasound (US) examinations were obtained for all treated veins. Successful EVLT was defined as US-documented absence of flow in the treated vein. EVLT failure was defined by US evidence of flow at any point in the treated vein segment at any time more than 1 week after the treatment date. A two-tailed Student t test was performed for statistical analysis and the null hypothesis was rejected at a P value less than .05.

RESULTS

One hundred eleven treated veins were followed up with US over 3-78 weeks (mean, 29.5 weeks). During this time, 85 treated veins (77.5%) remained closed. In this group of successfully treated veins, average energy delivered was 63.4 J/cm (range, 20.5-137.8 J/cm). The average energy delivered to the 26 veins (22.5%) in the failure group was 46.6 J/cm (range, 25.7-78 J/cm). This difference in delivered energy was statistically significant (P < .0001). No treatment failures were identified in patients who received doses of 80 J/cm or more.

CONCLUSION

EVLT is an effective method of incompetent saphenous vein treatment. Greater doses of energy delivered are associated with successful EVLT, particularly when doses of more than 80 J/cm are delivered.

Chronic venous insufficiency: clinical and duplex correlations. The Edinburgh Vein Study of venous disorders in the general population

OBJECTIVE

The objective of this study was to determine the prevalence of chronic venous insufficiency (CVI) in the general population and to correlate its clinical features with sonographically proven venous reflux.

DESIGN OF STUDY

The study design was a cross-sectional survey of the general population.

SUBJECTS AND METHOD

Ambulatory men and women, aged 18-64 years, were selected randomly from 12 general practices. Subjects were examined for CVI. Eight segments of the deep and superficial veins were assessed for reflux by means of duplex scanning.

RESULTS

A total of 1566 subjects were screened (867 women, mean age 44.8 years; 699 men, mean age 45.8 years) of whom 124 were diagnosed as having CVI: 95, grade 1; 19, grade 2; and 10, grade 3. The age-adjusted prevalence for the whole population was 9.4% in men and 6.6% in women. Prevalence of CVI correlated closely with age and sex, being 21.2% in men >50 years and 12.0% in women >50 years. Heaviness and tension, and a feeling of swelling, aching, and itching, were significantly associated with worsening grade of CVI. CVI was significantly associated with reflux in all deep and superficial segments. The frequency of reflux in both superficial and deep segments increased with the clinical severity of disease. In 30.8% of subjects with CVI in the left leg, reflux was limited to the superficial system.

CONCLUSIONS

The prevalence of CVI rises steeply with age. There is a strong correlation between venous symptoms and the presence and severity of CVI. CVI is associated in approximately one third of the subjects with incompetence limited to the superficial system and in these a good therapeutic outcome could be expected from surgery to the superficial veins. The severity of clinical features, including Basle CVI grade 1, correlates significantly with prevalence of valvular reflux in the deep and superficial systems. If leg ulcers are to be prevented by timely intervention, a better understanding of the natural history of the association between presenting features and disordered hemodynamics is required.

Infrequent early recanalization of greater saphenous vein after endovenous laser treatment

OBJECTIVE

The frequency of recanalization of the greater saphenous vein (GSV) after endovenous laser treatment (ELT) is unclear. This study was undertaken to establish the incidence of early recanalization after ELT and to study the histopathologic features of reperfused and excised GSV.

METHODS

One hundred nine GSV in 85 consecutive patients with clinical stage C(2-6) E(P,S) A(S,P,D) P(R) disease were treated with ELT. Twelve months of follow-up with duplex scanning at regular intervals was possible in 104 treated veins (95.4%) in 82 patients (96.5%). Recanalized vessels were removed surgically and examined at histopathology.

RESULTS

ELT-induced occlusion proved permanent at duplex scanning over 12 months of follow-up in 94 of 104 GSV (90.4%) in 73 patients. In 4 patients, 5 GSV (4.8%) were recanalized completely after 1 week, after 3 months (n = 3), or after 12 months. Another 5 GSV (4.8%) in 5 patients exhibited incomplete proximal recanalization over the 12 months of follow-up. Finally, 9 recanalized vessels (8.6%) required further treatment with high ligation and stripping. Histopathologic analysis of recanalized GSV revealed a multiluminal pattern, as commonly noted in reperfusion after spontaneous thromboplebotic occlusion of the GSV. During follow-up, secondary incompetency of untreated lateral accessory saphenous veins was observed in two legs (1.9%).

CONCLUSION

Early recanalization requiring retreatment is observed in less than 10% of GSV after ELT. The histopathologic pattern mimics recanalization after thrombophlebotic occlusion.

The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency

PURPOSE

The purpose of this study was to identify the distribution of venous reflux in patients with different patterns of reflux with each class.

METHODS

Color-flow duplex imaging was used to evaluate the entire venous system from groin to ankle in 465 patients (594 limbs) belonging to different clinical CVI classes (0, 1, 2, and 3). A history of previous superficial thrombophlebitis was present in five limbs and past deep vein thrombosis in 70.

RESULTS

One hundred seventy eight (30%) limbs were normal and the remaining 416 (70%) had venous incompetence. Deep reflux was present exclusively in 19 limbs (3.2%), and the perforation system alone was involved in only three limbs (0.5%). However, isolated superficial incompetence was seen in 186 limbs (31.3%) and a combination of superficial with perforating alone was involved in 45 (7.6%). Incompetence in all three systems was seen in 99 extremities (16.7%). In addition, the superficial system was involved in 390 limbs, the perforators in 151, and the deep system in 178 limbs. Only a small percentage of those in class 0 had reflux, and most of them had a single site of incompetence. In class 1 the majority of the limbs had superficial reflux (90.3%), 10.3% of the limbs had deep venous reflux, and 6.9% were competent. Reflux in the superficial system was only seen in 80.7% of the limbs in class 1 and in one fifth of the limbs in classes 2 and 3. Isolated deep or perforated incompetence was rare in all classes. Variable combined patterns of reflux were seen more often in classes 2 and 3 (p < 0.0001). In classes 2 and 3 there were no differences in the number of incompetent sites in the superficial and deep venous systems or the patterns of reflux (p > 0.1). The number of incompetent perforators in class 3 tended to be higher than that in class 2, especially in the below-knee segment, but no significant differences were seen. Distal reflux was present in the majority of the limbs in all symptomatic classes (1, 2, and 3).

CONCLUSIONS

The distribution and extent of reflux is strongly associated with clinical severity of CVI through class 2. Distal venous reflux is present in at least 80% of the symptomatic limbs. Deep venous thrombosis may not be a prerequisite for the development of skin changes or ulceration in about 75% of the limbs. Superficial venous surgery could be beneficial to at least one third of patients with skin changes or ulceration.

Criteria for defining significant central vein stenosis with duplex ultrasound

OBJECTIVE

To determine criteria for a clinically significant vein stenosis with duplex ultrasound (DU) in patients with signs and symptoms of central venous outflow obstruction.

METHODS

Patients referred with swelling with or without pain to the vascular laboratory to detect vein obstruction were evaluated. These were mostly patients who had liver transplant, dialysis access, and tumors. All patients had DU prior to any other imaging. Only patients who subsequently underwent phlebography with intention to treat the vein stenosis were included in the study. A phlebogram with two views, pressure measurements across the stenosis, and intravascular ultrasound in selected cases were performed in all patients with suspected stenosis on DU. Adjacent ipsilateral normal vein segments were utilized as controls. The invasive tests were performed within 2 weeks of the DU. Follow-up was performed with DU at discharge and within 6 months of the procedure. A pressure gradient of =3 mm Hg across the stenosis was used to define a >50% diameter reduction, which was also determined by phlebographic measurement.

RESULTS

Thirty-seven patients, 20 males and 17 females, mean age 54 years, range 27 to 79, were evaluated. Forty-one stenotic venous sites were detected with DU; inferior vena cava 14, superior vena cava 2, portal 2, iliac 11, common femoral 3, brachiocephalic 3, subclavian 5, and axillary vein 1. Phlebography identified 37 of these stenoses and demonstrated two more not seen by DU. Pressure measurements confirmed 39 of those detected by DU. The best criterion by DU to detect a >50% stenosis was a poststenotic to pre-stenotic peak vein velocity ratio of 2.5. The presence of poststenotic turbulence and planimetric calculations of the diameter reduction increased the diagnostic confidence but not the accuracy. Using the pressure gradient of >/=3 mm Hg as a reference test, there were two false positive and two false negative exams with DU, while phlebography had two false negative exams. The overall agreement of DU alone was 90% of phlebography >95% and when combined 100%. Intravascular ultrasound identified correctly all 11 lesions in 11 patients. After angioplasty and stenting, there was a dramatic reduction in the edema in most patients particularly in those that had a caval stenosis. Restenosis was identified by DU in 5/29 (17%) patients at 6 months that were confirmed by phlebography and pressure measurements. Reintervention was performed in four and it was successful in three.

CONCLUSIONS

DU is a sensitive method to identify a clinically significant vein stenosis. A peak vein velocity ratio of >2.5 across the stenosis is the best criterion to use for the presence of a pressure gradient of =3 mm Hg. DU can be used to select patients for intervention and also to monitor the success of the treatment during follow-up.

Prevalence of venous reflux in the general population on duplex scanning: the Edinburgh vein study

PURPOSE

The prevalence of reflux in the deep and superficial venous systems in the Edinburgh population and the relationship between patterns of reflux and the presence of venous disease on clinical examination were studied.

METHODS

A cross-sectional survey was done on men and women ranging in age from 18 to 64 years, randomly selected from 12 general practices. The presence of varicose veins and chronic venous insufficiency was noted on clinical examination, as was the duration of venous reflux by means of duplex scanning in 8 vein segments on each leg. Results were compared using cut-off points for reflux duration (RD) of 0.5 seconds or more (RD >/= 0.5) and more than 1.0 second (RD > 1.0) to define reflux.

RESULTS

There were 1566 study participants, 867 women and 699 men. The prevalence of reflux was similar in the right and left legs. The proportion of participants with reflux was highest in the lower thigh long saphenous vein (LSV) segment (18.6% in the right leg and 17.5% in the left leg for RD >/= 0.5), followed by the above knee popliteal segments (12.3% in the right leg and 11.0% in the left leg for RD >/= 0.5), the below knee popliteal (11.3% in the right leg and 9.5% in the left leg for RD >/= 0.5), upper LSV (10.0% in the right leg and 10.8% in the left leg for RD >/= 0.5) segments, the common femoral vein segments (7.8% in the right leg and 8.0% in the left leg for RD >/= 0.5), the lower superficial femoral vein (SFV) segments (6.6% in the right leg and 6.4% in the left leg for RD >/= 0.5), and the upper SFV (5.2% in the right leg and 4.7% in the left leg for RD >/= 0.5) and short saphenous vein (SSV) (4.6% in the right leg and 5.6% in the left leg for an RD >/= 0.5) segments. In the superficial vein segments, there was little difference in the occurrence of reflux whether RD >/= 0.5 or RD > 1.0 was used; but in the different deep vein segments, the prevalence of reflux was 2 to 4 times greater for RD >/= 0.5 rather than RD > 1.0. Men had a higher prevalence of reflux in the deep vein segments than women, reaching statistical significance (P </=.01) in 4 of 5 segments for RD >/= 0.5. In general, the prevalence of reflux increased with age. Those with "venous disease" had a significantly higher prevalence of reflux in all vein segments than those with "no disease" (P </=.001).

CONCLUSION

The prevalence of venous reflux in the general population was related to the presence of "venous disease," although it was also present in those without clinically apparent disease. There was a higher prevalence of reflux in the deep veins in men than the deep veins in women. Follow-up study of the population will determine the extent to which reflux is a predictor of future disease and complications.

Venous ulceration and saphenous ligation

Over an 8-year period prospective series of 213 consecutive patients with venous ulceration of 232 limbs has been studied. By means of clinical, hand-held Doppler ultrasound and comprehensive ascending and descending venography examination, it was possible to identify underlying morphological abnormalities and on the basis of these to divide patients into four principal types. Type I:4%--ankle perforator incompetence alone; Type II:39%--ankle perforator and saphenous incompetence; Type III: 35%--primary deep incompetence (usually associated with perforator and saphenous incompetence); Type IV:22%--patients with postphlebitic damage. This study reports the outcome of Type II patients that have been treated by saphenous ligation alone (no perforator ligation). Healing was maintained over a mean period of 3.5 years in all but five patients. In these, other factors were shown in retrospect to be contributory to failed healing. It is concluded, therefore, that approximately 40% of venous ulcers can be ascribed to a combination of incompetence of saphenous and ankle perforating veins and that medium-term healing can be achieved in at least 90% of these by saphenous ligation alone.

Presentation of the patient with recurrent varices after surgery (REVAS)

AIM

To identify in patients with recurrent varices after surgery (REVAS) the clinical, etiologic, anatomic, and pathophysiologic patterns according to the CEAP classification, as well as the site, source, causes of recurrence, and contributory factors by using the REVAS classification.

METHODS

Centers from eight countries enrolled patients with superficial vein reflux that had had a previous operation. A physical examination and a duplex ultrasound scan were performed at the first visit. This was repeated between 2 to 8 weeks after by the same physician and by another physician within the same time frame. The perforator, deep, and superficial veins systems as well as their accessories and tributaries were examined. A form based on the CEAP and the REVAS classification was used and the data were entered in a customized database.

RESULTS

Fourteen institutions enrolled 170 patients (199 lower limbs) in 1 year. Their mean age was 56 years, and 69% were women. Most of them had undergone one surgical procedure before enrollment (76.6%). Most had varicose veins and swelling (70.9%), and the rest had skin damage (29.1%). More than 90% had primary etiology. The saphenofemoral junction (47.2%) and leg perforators (54.7%) were the areas most often involved by recurrent reflux. Reflux in deep veins was detected in 27.4%. Class 2 (varicose veins) alone was present in 24.6% of limbs, two classes were present in 43%, and three in 24%. Neovascularization was as frequent as technical failure (20% vs 19%); both were seen in 17%. In 35%, the cause was uncertain or unknown. When recurrence occurred at a different site, development of reflux in new sites was found in 32% of limbs. Of the contributing factors, family history and lifestyle had the highest prevalence. Women had significantly more procedures than men, despite a clear trend toward more severe disease in the latter.

CONCLUSIONS

Most patients were symptomatic with several clinical forms of presentation. The REVAS classification, together with CEAP, gives significant and more appropriate information for evaluating and following-up patients with chronic venous disease who have had an intervention.

Reduced recanalization rates of the great saphenous vein after endovenous laser treatment with increased energy dosing: Definition of a threshold for the endovenous fluence equivalent

BACKGROUND

Recent reports indicated a correlation between the amount of energy released during endovenous laser treatment (ELT) of the great saphenous vein (GSV) and the success and durability of the procedure. Our objective was to analyze the influence of increased energy dosing on immediate occlusion and recanalization rates after ELT of the GSV.

METHODS

GSVs were treated with either 15 or 30 W of laser power by using a 940-nm diode laser with continuous fiber pullback and tumescent local anesthesia. Patients were followed up prospectively with duplex ultrasonography at day 1 and at 1, 3, 6, and 12 months.

RESULTS

A total of 114 GSVs were treated with 15 W, and 149 GSVs were treated with 30 W. The average endovenous fluence equivalents were 12.8 +/- 5.1 J/cm2 and 35.1 +/- 15.6 J/cm2, respectively. GSV occlusion rates according to the method of Kaplan and Meier for the 15- and 30-W groups were 95.6% and 100%, respectively, at day 1, 90.4% and 100% at 3 months, and 82.7% and 97.0% at 12 months after ELT (log-rank; P = .001). An endovenous fluence equivalent exceeding 20 J/cm2 was associated with durable GSV occlusion after 12 months' follow-up, thus suggesting a schedule for dosing of laser energy with respect to the vein diameter.

CONCLUSIONS

Higher dosing of laser energy shows a 100% immediate success rate and a significantly reduced recanalization rate during 12 months' follow-up.

Patterns of venous reflux in limbs with skin changes associated with chronic venous insufficiency

The distribution of venous reflux in patients with skin changes associated with chronic venous insufficiency presenting to a specialist clinic was assessed. A total of 300 limbs in 153 patients were examined by Doppler ultrasonography with colour-flow imaging for the presence of venous reflux in superficial veins, deep veins and medial perforating veins, both above and below the knee. Ninety-eight limbs had skin changes, which included hyperpigmentation, lipodermatosclerosis, atrophie blanche and ulceration. Of this group, 2 per cent had no evidence of venous reflux on duplex scanning, 39 per cent had deep vein incompetence, 57 per cent had superficial vein incompetence and 2 per cent had isolated medial perforating vein reflux. Of 25 limbs with ulceration, 13 had superficial and 12 deep vein reflux. A total of 202 legs, which included 20 normal control limbs, had no skin changes; 22.3 per cent of these had no venous reflux, 8.4 per cent had deep vein incompetence, 65.3 per cent had superficial incompetence and 4.0 per cent had isolated medial calf perforating vein incompetence.

Chronic venous insufficiency and varicose veins of the lower extremities

Chronic venous insufficiency (CVI) of the lower extremities manifests itself in various clinical spectrums, ranging from asymptomatic but cosmetic problems to severe symptoms, such as venous ulcer. CVI is a relatively common medical problem but is often overlooked by healthcare providers because of an underappreciation of the magnitude and impact of the problem, as well as incomplete recognition of the various presenting manifestations of primary and secondary venous disorders. The prevalence of CVI in South Korea is expected to increase, given the possible underdiagnoses of CVI, the increase in obesity and an aging population. This article reviews the pathophysiology of CVI of the lower extremities and highlights the role of duplex ultrasound in its diagnosis and radiofrequency ablation, and iliac vein stenting in its management.

Venous hemodynamic abnormalities in patients with leg ulceration

PURPOSE

Venous ulceration in the leg has been predominantly associated with deep venous insufficiency, although a few reports have implicated the superficial veins. The aim of this study was to identify the distribution of valvular incompetence in patients with active leg ulceration.

PATIENTS AND METHODS

Color flow duplex imaging (CFDI) ultrasonography was used to evaluate the entire venous system--superficial, perforator and deep--from groin to ankle in 112 limbs of 94 patients with venous leg ulcers.

RESULTS

Seventy two limbs (64%) had multisystem incompetence and 36 (32%) had one system involved only, whereas in 4 limbs (4%) there was no venous incompetence. Deep venous reflux exclusively was present in 7 limbs (6%) and the perforator system alone was involved only in 3 limbs (3%). However, isolated superficial incompetence was seen in 26 extremities (23%) and combination of superficial with perforator system alone in 23 (21%). In addition, reflux overall in the superficial system (alone and in combination with perforator and deep systems) was seen in 94 limbs (84%). The most common pattern (28%) of abnormality was reflux in all systems, superficial, perforator, and deep.

CONCLUSIONS

The results of this study show that variable combined patterns account for over two thirds of patients with ulceration. No comprehensive surgical policy for alleviating ulceration can be justified; we suggest that a complete evaluation of all venous systems from groin to ankle with CFDI ultrasonography in patients with venous ulceration is practical on a routine basis and will be particularly valuable before surgery in order to target intervention at specific incompetent sites.

Balloon dilation and stenting of chronic iliac vein obstruction: technical aspects and early clinical outcome

PURPOSE

To describe the technical aspects of percutaneous balloon dilation and stenting for the treatment of venous outflow obstruction in chronic venous insufficiency.

METHODS

Between March 1997 and December 1998, 94 consecutive patients (median age 48 years, range 14 to 80) with suspected iliac vein obstruction in 102 limbs were studied prospectively with the intent to treat any venous occlusion or stenosis verified during femoral vein cannulation. Data from the history, clinical examination, procedure, and follow-up were recorded. Preoperative indicators of obstruction were venographic evidence of occlusion, stenosis, or pelvic collateral vessels; increased arm-foot venous pressure differential; and abnormal hyperemia-induced venous pressure elevation.

RESULTS

Cannulation and technical success rates were 98% and 97%, respectively, with 118 Wallstents deployed in 77 veins. Primary, assisted primary, and secondary patency rates at 1 year were 82%, 91%, and 92%, respectively. Clinical improvement in pain and swelling was significant.

CONCLUSIONS

Stenting of benign iliac vein obstruction is a safe method with good short-term results. Venous lesions should always be stented; when treating iliocaval junction lesions, stents should be inserted well into the inferior vena cava. Absence of collateral vessels does not exclude the existence of significant obstruction, and their presence may indicate an obstruction not visualized. No gold standard for accurate pre- or intraoperative patient selection is currently available.

The effect of long saphenous vein stripping on quality of life

PURPOSE

Long saphenous vein (LSV) stripping in the treatment of varicose veins may reduce the recurrence of varices but may also increase morbidity rates. The effect of stripping on health-related quality of life (HRQoL) is unknown. The aim of this study was to examine the effect of LSV surgery, with and without successful stripping, on HRQoL.

METHODS

This prospective study comprises 102 consecutive patients who underwent varicose vein surgery that included attempted stripping of the LSV to the knee. HRQoL was assessed before surgery and at 4 weeks, 6 months, and 2 years after surgery with the Aberdeen varicose vein severity score (AVSS; disease-specific) and the Short-Form 36 (SF-36; generic). Patients defined as stripped were those in whom complete thigh stripping to the knee was confirmed with postoperative duplex scanning at 2 years. Patients defined as incompletely stripped were those in whom any LSV remnant was found in the thigh after surgery. Deep venous reflux (DVR) was defined as reflux of 0.5 seconds or more in at least the popliteal vein.

RESULTS

Sixty-six of 102 patients (65%) provided complete HRQoL data at all four time points. At baseline, there was no significant difference between patients who were stripped (n = 25) and incompletely stripped (n = 41) in terms of AVSS, SF-36, age, gender, DVR, or CEAP grade. Significantly more patients in the incompletely stripped group underwent surgery for recurrent disease (29/41, 71%, versus 8/25, 32%; P =.002, with chi(2) test). Both groups gained significant improvements in AVSS scores for as much as 2 years. After adjustment for recurrent disease, stripping conferred additional benefit in terms of AVSS at 6 months (median [interquartile range]) (9 [4 to 16] versus 15 [9 to 24]; P =.031) and 2 years (7 [2 to 10] versus 9 [5 to 15]; P =.014), which was statistically significant in patients without preoperative DVR but not significant in patients with preoperative DVR. SF-36 scores were not affected by stripping.

CONCLUSION

LSV surgery leads to a significant improvement in disease-specific HRQoL for as much as 2 years. In patients without DVR, stripping to the knee confers additional benefit.

Correction of lower extremity deep venous incompetence by ablation of superficial venous reflux

Chronic venous insufficiency which produces lipodermatosclerosis, varicosities, or ulceration, is frequently caused by superficial venous reflux and deep venous incompetence. The anatomy of venous insufficiency has been clarified with duplex ultrasound, thus allowing appropriately directed therapy. However, postoperative venous physiology in patients undergoing superficial venous ablation has been infrequently reported. This study was undertaken to document the effect of superficial venous ablation on deep venous reflux. Between April 1994 and May 1995, 45 patients were examined preoperatively with duplex ultrasound. All patients had symptomatic venous insufficiency and were found to have greater saphenous vein reflux. Clinical classification of venous insufficiency (according to the criteria of the joint councils of the vascular societies) included class I in 30 patients, class II in 12, and class III in 3. Seventeen patients (38%) had reflux in the femoral venous system in addition to superficial reflux. All patients underwent removal of the proximal greater saphenous vein in concert with multiple stab avulsions of identified varicosities. Postoperative interrogation of the venous system revealed that in 16 (94%) of 17 patients, coexistent femoral venous insufficiency completely resolved. Thus ablation of superficial venous reflux eliminated incompetence in the deep venous system in patients with combined disease. These preliminary results suggest that superficial venous incompetence may be a cause of deep venous insufficiency. Whereas alternative methods to correct deep venous insufficiency have met with limited success, it appears that saphenectomy (when combined disease is present) may be effective in correction of deep venous reflux.