Miguel Leon

Superficial venous insufficiency: Correlation of anatomic extent of reflux with clinical symptoms and signs

PURPOSE The aim of this study was to assess the distribution and extent of valvular incompetence in patients with reflux confined to the superficial venous system and correlate the extent of such reflux with clinical symptoms and signs. METHODS Two hundred fifty-five limbs of 217 patients with superficial venous insufficiency and normal perforating and deep veins were examined with color-flow duplex imaging. One hundred twenty-three limbs (48.2%) of 102 patients had reflux confined to the long saphenous system, 83 limbs (32.6%) of 72 patients had reflux confined to the the short saphenous system, and 49 limbs (19.2%) of 43 patients had reflux in both long and short saphenous systems. RESULTS In the long saphenous system the commonest pattern of reflux was that which extended throughout the length of long saphenous vein (LSV) (47%). Ache, swelling, and skin changes were common in the presence of below knee reflux irrespective whether the thigh segment was involved. Ulceration (8%) was found only in limbs with reflux extending throughout the length of LSV. In the short saphenous system the most common pattern of reflux extended throughout the length of short saphenous vein (SSV) (57%) without involvement of Giacomini or gastrocnemial veins. Ache and swelling were present in 62% and 72% of the limbs, but this incidence was not related to the extent of reflux. Swelling, skin changes, and ulceration occurred only when the whole of the SSV was involved. In the limbs with reflux in both the long and short saphenous systems, the most common pattern of reflux extended throughout the length of both systems (45%). In these limbs the incidence of swelling was 80%. The incidence of skin changes went from 44% when the below-knee segment of the LSV was involved to 73% when reflux occurred throughout the LSV and SSV. Ulceration (14%) was found only in the latter situation. Variable patterns of saphenogastrocnemial termination were seen. In 57.8% of the limbs SSV joined the popliteal vein just above the popliteal crease, whereas the SSV terminated in the thigh in 26.6%. CONCLUSIONS We conclude that ache, ankle edema, and skin changes in limbs with reflux confined to the superficial venous system are predominantly associated with reflux in the below-knee veins. Ulceration is found only when the whole of the LSV is involved (8%) or when reflux is extensive in both LSV and SSV (14%).

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.

Venous reflux in patients with previous deep venous thrombosis: Correlation with ulceration and other symptoms ☆ ☆☆

PURPOSE Deep vein thrombosis (DVT) in many cases leads to chronic symptoms in the damaged leg, even though the affected veins have recanalized. The major hemodynamic defect in such recanalized veins is reflux. The incidence and extent of reflux has been studied in patients with proven DVT and correlated with concurrent symptoms. METHODS Two hundred seventeen limbs in 183 patients were examined by duplex scanning from January 1989 to October 1992. All limbs had previous DVT diagnosed by venography. Sites and extent (proximal, distal, or both) of reflux were identified by meticulous duplex scanning of the whole venous system and correlated with presenting symptoms. RESULTS The patients were classified into nine groups on the basis of the classification of the system involved (superficial, deep, or superficial and deep) and whether the reflux was found proximal or distal to the knee or both. Eight-one limbs belong to chronic venous insufficiency class 1, 92 belong to class 2, and 38 belong to class 3. Reflux was confined to the deep venous system in 84 limbs (38.7%), to the superficial system in 31 (14.3%) limbs, and to both systems in 102 (47%) limbs. It was confined to proximal veins only in 48 (22.1%) limbs, distal only in 56 (25.8%) limbs and throughout the limb in 113 (52.1%) limbs. The incidence of swelling was increased by distal or a combination of proximal and distal reflux regardless of which system was involved. In limbs with superficial venous insufficiency (SVI) or deep venous insufficiency (DVI) only, the incidence of skin changes was not affected by the extent of reflux. However, in limbs with combined SVI and DVI, it was increased in the presence of reflux throughout the limb. Absence of distal reflux was associated with a low incidence of skin changes even in the presence of DVI. Ulceration increased with an increased extent of reflux in the presence of SVI. Absence of superficial reflux was associated with a low incidence, even in the presence of DVI. CONCLUSIONS The data suggest that as far as the skin changes and ulceration are concerned, distal reflux and reflux in the superficial veins are more harmful than reflux confined to the deep veins, even when such reflux extends throughout the deep venous system.

Recurrent varicose veins: Investigation of the pattern and extent of reflux with color flow duplex scanning

BACKGROUND This study was conducted to investigate with color flow duplex imaging the patterns and the extent of venous valvular incompetence in recurrent varicose vein disease. METHODS One hundred thirty-four limbs of 123 unselected patients who arrived in the outpatient clinic with residual or recurrent varicose veins after undergoing an operation were included. Limbs with history of compression sclerotherapy before or after the operation were excluded. The long (LSV) and short saphenous vein (SSV) systems in all limbs were examined with color flow duplex imaging for detection of the sites and the extent of reflux. RESULTS Various patterns of recurrent valvular reflux were seen in both the LSV and SSV systems. Reflux confined to saphenofemoral junction alone or associated with reflux in the LSV system was seen in 29% of the limbs. Reflux in the whole LSV system was very common after saphenofemoral junction ligation was performed (chi-squared test, p<0.01). Most of the limbs (53%) with recurrence in the LSV system had incompetent perforating veins. Incompetent perforators in the thigh were more common after ligation (23%) than stripping (10%), but this finding was not true in the calf. After saphenopopliteal junction ligation was performed, the more common pattern was the reflux in the SSV (75%), whereas after SSV stripping was performed, it was the reflux in the SSV tributaries (64%). CONCLUSIONS Multiple patterns of reflux develop in recurrent varicose veins. Precise mapping of the reflux and identification of the possible causes are required to instigate appropriate treatment. Color flow duplex imaging is an efficient noninvasive diagnostic technique to identify venous reflux.

New insights into the pathophysiologic condition of venous ulceration with color-flow duplex imaging: Implications for treatment?

PURPOSE This study was conducted to investigate the distribution of reflux in the veins adjacent to or within the venous ulcer (local) and to correlate it with the pattern of disease of the axial veins (all veins away from the ulcer area) of the affected limb. METHODS Forty-three ulcers in 34 legs of 33 patients were examined with color-flow duplex imaging. The veins in the area of the ulcer were scanned with a sterile technique. RESULTS In 17 legs (50%) there was documented past deep venous thrombosis. All of the 34 limbs had reflux in the superficial or deep axial veins either alone or in combination. Fifteen of these limbs (44%) also had perforating vein incompetence, but none had perforator incompetence alone. Six ulcers showed no evidence of reflux in the local veins when scanned through the ulcer bed despite the presence of reflux in the axial veins of the limb. In 13 limbs with 17 ulcers, either the superficial axial veins alone or the deep axial veins alone were affected (with or without associated perforator incompetence). Examination of the local veins associated with these 17 ulcers revealed a similar pattern of reflux to that seen in the axial veins in 13 cases, with the remaining 4 ulcers showing no local venous abnormality. The pattern of reflux was less predictable at the local ulcer level in limbs where both superficial and deep venous incompetence coexisted in the axial veins. Only 7 of the 26 ulcers (27%) in these limbs had similar evidence of combined superficial and deep reflux in the local ulcer veins, whereas 10 ulcers (39%) were associated with local reflux in the superficial or deep veins alone. CONCLUSIONS These data show that 86% (37/43) of the ulcers has some degree of reflux in the local area, the pattern of which may differ from the axial vein disease. Treatment of the local hemodynamic abnormalities may be an important factor in the healing of the ulcers and in the prevention of their recurrence.

Popliteal vein entrapment in the normal population.

The aim of this study was to determine the incidence and severity of popliteal vein compression by full knee extension in the normal population. The popliteal veins in 100 healthy volunteers (200 limbs) with no history of previous deep vein thrombosis (DVT) or venous obstruction were examined using duplex scanning with the knee slightly flexed and then fully extended. Knee extension produced complete obstruction in 17 subjects and severe obstruction (< 50% decrease in diameter) in a further 10 subjects. Thirteen subjects had unilateral compression and 14 bilateral. The 27 subjects were tested for functional venous outflow obstruction with air plethysmography. In flexion, the outflow fraction was normal (> 40%) in all subjects. With the knee fully extended, severe or complete venous obstruction (outflow fraction < 10%) was found in eight subjects. Moderate obstruction (outflow fraction 10-40%) was found in all the remaining 19 subjects. When digital compression of the long saphenous vein was performed, these subjects also demonstrated severe outflow obstruction. Although the incidence of symptoms of functional venous obstruction is rare in the general population, these findings have important implications for venous stasis for patients on the operating table and in those having prolonged bed rest. Studies investigating the association between popliteal vein compression and postoperative deep venous thrombosis are needed.

The Combination of Liquid Crystal Thermography and Duplex Scanning in the Diagnosis of Deep Vein Thrombosis

One hundred patients with clinically suspected deep vein thrombosis (DVT) were studied by liquid crystal thermography (LCT), duplex scanning and venography. Liquid crystal thermography was found to have a negative predictive value of 97% if performed within 1 week of the onset of symptoms. Duplex scanning had a sensitivity of 93% and specificity of 91% for all thrombi (proximal and calf). On the basis of these results a plan of investigation has been formulated that would avoid duplex scanning and venography in 39 of the 100 patients. Duplex scanning alone would be appropriate in 56 of the remaining 61 patients. Only six patients would be unsuitable for duplex scanning because of a very tense tender leg and require venography. The plan would miss one calf thrombus and result in treating three patients unnecessarily. This policy would be not only effective but also cost-effective.

The effect of iloprost in patients with rest pain

Thirty-four patients with ischaemic rest pain in 42 limbs and ankle pressure equal to or less than 50 mmHg have been treated with intravenous infusion of synthetic prostacyclin (iloprost) for eight days. Leg blood flow was measured with air plethysmography before treatment, on day 4 and day 8 of treatment. Total relief of pain for at least 6 weeks occurred in 91% of patients with leg blood flow > or = 40 ml/min, in 18% with leg flow 30-39 ml/min and in 11% with leg flow < 30 ml/min. Complete relief of pain for at least 6 weeks occurred in 92% of patients in whose limbs the blood flow on day 8 was greater than 50 ml/min but only in 6% with blood flow less than 50 ml/min. These results indicate that iloprost increases leg blood flow and that patients likely to respond can be identified from the baseline air plethysmographic measurement of leg blood flow.