Ross Christie

Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography.

OBJECTIVE We observed long-term venous ultrasound and plethysmographic changes after varicose vein surgery, to determine factors that influence recurrence. METHODS AND MATERIALS This observational sequential prospective study was carried out in an institutional referral center with day surgery. Subjects were 92 consecutive patients, ages 20 to 75 years, with symptomatic varicose veins in 127 limbs, who were able to complete regular assessment. Superficial varicose vein surgery included significant perforator vessels only, defined at preoperative duplex ultrasound scanning and air plethysmography. Similar follow-up assessments were performed at 3 weeks, 3 months, and 1, 3, and 5 years. RESULTS At 3 weeks venous reflux but not muscle pump function was consistently improved in all limbs. However, inadequate surgery at the major junctions was clearly identified as contributing to recurrence of disease in 7.2% of limbs. Recurrence of varicose veins occurred in 1 of 100 limbs (1%) at the saphenofemoral junction and in 8 of 33 (25%) limbs at the saphenopopliteal junction. However, after 3 years disease recurrence at these sites had increased to 23% and 52%, respectively. Incompetent perforator vessels increased progressively in number. Clinical recurrence was 47.1%, and consistent with this was gradual deterioration in air plethysmographic measures of reflux, with physiologic recurrence (venous filling index, >2 mL/s) in 66% at 5 years. Late recurrence was predicted in limbs with multiple sites of reflux preoperatively, venous filling index greater than 2 mL/s, and some other persistent abnormality at duplex scanning at 3 weeks. There was no recurrence in 40 limbs in which these factors were normal at at 3 weeks. However, 29 of 53 limbs with normal venous filling index after operative intervention had deteriorated at 3 years. CONCLUSION Incomplete superficial surgery, in particular at the saphenofemoral and saphenopopliteal junctions, is a less frequent cause of recurrent disease, and neovascular reconnection and persistent abnormal venous function are the major contributors to disease recurrence.

Incidence of deep vein thrombosis after varicose vein surgery.

Varicose vein surgery is generally considered to have little risk of postoperative deep vein thrombosis (DVT). This prospective study examined the incidence of DVT in patients undergoing varicose vein surgery.

Recurrent Varicose Veins: Patterns of Reflux and Clinical Severity

Duplex scanning was used to determine patterns of recurrent varicose veins in 264 limbs and to relate these to clinical factors. All limbs had previously undergone sapheno-femoral ligation in the groin. A recurrent sapheno-femoral junction was present in 172 (65.2%). Incompetence was found in long or short saphenous veins in 232 limbs (87.9%), perforators in 176 (66.7%), and deep veins in 156 (59.1%). Residual long saphenous veins were present in 43.4% and 73.6% of limbs that were with and without stripped long saphenous veins, respectively. An incompetent thigh perforator was present in 14.0% and 15.3% of these two groups, respectively. Multiple sites of incompetence were observed in the majority (75.4%). In general, no particular reflux pattern in the groin was related to an increased incidence of ulceration. However, ulceration was more frequent in limbs with deep reflux to knee or below-knee levels. None of those with isolated reflux in the groin that was unrelated to the common femoral vein had ulceration. The pattern of reflux was unrelated to striping or non-striping of the long saphenous veins and the time since initial surgery. A history of deep vein thrombosis was invariably associated with some degree of deep reflux. A system of recurrent patterns in the groin is described for the purpose of surgical audit. In 15.1%, recurrence was attributed with some confidence to inadequate surgery. These results indicate that the pattern of recurrence is highly variable and often with multiple sites of incompetence. In a few instances, the pattern of recurrence was associated with specific clinical factors. A full work-up including duplex scanning is recommended.

Obesity and Impaired Venous Function

OBJECTIVES The clinical severity of venous disease is often worse in obese patients. The objectives of this study were to compare lower limb venous physiology assessed by air plethysmography in a large group of obese and normal-weight patients; to consider the effect of posture on these measures and on foot vein pressure in a smaller cohort. METHODS Venous function was assessed using air plethysmography and duplex scanning in 934 consecutive patients presenting for assessment of venous disease. These were grouped into obese or non-obese categories. A smaller group of twenty patients with a range of body weights were randomly selected from a database of patients with varicose veins. Foot vein pressures and femoral vein diameter were measured standing, sitting, lying and ambulating. RESULTS Venous disease was more clinically severe in the obese limbs (CEAP C5&6 non-obese group 20.5%, obese group 35.4%, p<0.001 chi(2)). Venous reflux was worse in the obese but measures of muscle pump function were better. Residual volumes and fractions were better in the obese (mean residual volume, non-obese 60 SD 36, obese 50 SD 42, p<0.001 t test). In the smaller study group weight correlated with the diameter of the superficial femoral vein (r=0.50), ambulatory venous pressure (r=0.45), venous filling index (r=0.49) and the ejection volume (r=0.38, p<0.05). The foot venous pressure was significantly greater in the obese in all positions. CONCLUSION The CEAP clinical stage of venous disease is more advanced in obese patients than non-obese patients with comparable anatomical patterns of venous incompetence. This may be the result of raised intra-abdominal pressure reported in previous studies, leading to greater reflux, increased vein diameter and venous pressures.

The use of video image analysis for the measurement of venous ulcers

Summary The accurate measurement of the size of skin wounds and ulceration is important for comparing the efficiency of treatment modalities and for monitoring progress in the individual patient. Although various methods of differing sophistication are in use, many of the common simpler techniques lack accuracy and reliability.

Venous physiology in the different patterns of recurrent varicose veins and the relationship to clinical severity

Venous function measured by air-plethysmography (APG) was compared to anatomical patterns of reflux assessed by duplex scanning and associated clinical features in 253 limbs with recurrent varicose veins following previous superficial venous surgery. The results showed that a previous history of deep venous thrombosis, previous procedure with preservation of the long saphenous vein, and a history of healed ulcer or current ulcer were each associated with worse venous function. Patterns of reflux which included multiple sites of reflux and presence of deep incompetence were also associated with worse venous function. Where there was reflux in the groin, limbs with a wide recurrent saphenofemoral junction presented the worst venous filling time and venous filling index, whereas those with reflux unrelated to the common femoral vein had nearly normal venous physiology and occurred almost exclusively in females. The other patterns of recurrence in the groin were physiologically indistinguishable from each other. In conclusion, certain patterns of reflux, clinical and operative features are associated with worse venous physiology in limbs with recurrent varicose veins. These features of recurrence with more severe physiological disturbance may necessitate a higher priority for surgical intervention.

Prospective Study of Natural History of Deep Vein Thrombosis: Early Predictors of Poor Late Outcomes

BACKGROUND A proportion of patients with deep vein thrombosis (DVT) will develop postthrombotic syndrome (PTS). Currently, the only clearly identified risk factors for developing PTS are recurrent ipsilateral DVT and extensive proximal disease. The aim of the study was to assess the natural history of DVT and identify early predictors of poor clinical outcome at 5 years. METHODS Patients with suspected acute DVT in the lower limb were assessed prospectively. All patients with a confirmed DVT were asked to participate in this study. Within 7-10 days after diagnosis of DVT, patients underwent a further review, involving clinical, ultrasound, and air plethysmography assessment of both lower limbs. Patients were reassessed at regular intervals for 5 years. RESULTS One hundred twenty-two limbs in 114 patients were included in this study. Thrombus regression occurred in two phases, with a rapid regression between 10 days and 3 months, and a more gradual regression thereafter. Reflux developed as thrombus regression occurred. Segmental reflux progressed to axial deep reflux and continued to deteriorate in a significant proportion of patients with iliofemoral-popliteal-calf DVT throughout the 5-year study period. Similarly, venous filling index became progressively more abnormal, in this group, over the course of the study. Four risk factors for PTS were identified as best predictors: extensive clot load on presentation; <50% clot regression at 6 months; venous filling index >2.5 mL/sec; and abnormal outflow rate (<0.6). Patients with three or more of these risk factors had a significant risk of developing PTS with sensitivity 100%, specificity 83%, and positive predictive value 67%. Patients scoring 2 or less did not have PTS at 5 years with a negative predictive value of 100%. CONCLUSIONS This is the first study to show that venous assessment at 6 months post-DVT can predict PTS at 5 years. Those who will not develop PTS can be reassured of this at 6 months.

Microcirculation and Venous Disease: Effects of Raised Venous Pressure, Walking and Temperature

While the exact pathophysiological mechanisms resulting in the skin changes and ulceration of the skin in the limbs of patients with severe chronic venous insufficiency (CVI) remain unclear, various investigative modalities have increased our understanding of the characteristic microcircultory changes present.