S. Sarin

Venous ulcers and the superficial venous system

PURPOSE The purpose of this study is to identify the anatomic location of venous disease in patients with venous ulceration and chronic venous insufficiency. METHODS Both limbs of 59 consecutive patients attending the Middlesex Hospital Vascular Laboratory (London, U.K.) with venous ulceration were assessed by color duplex ultrasound scanning to determine the location of venous disease. RESULTS Isolated deep venous reflux was present in only 12 limbs (15%). A combination of deep and superficial venous reflux was found in 25 limbs (32%), and in 42 limbs (53%) there was only superficial venous reflux. CONCLUSION In just over half the patients with venous ulceration, the disease is confined to the superficial venous system. This group of patients may benefit from surgical treatment. This study emphasizes the need for vascular laboratory investigation of patients with leg ulceration.

Medial calf perforators in venous disease: The significance of outward flow

The role of medial calf perforators in the initiation or promotion of venous disease is incompletely understood. The purpose of this study was to define the direction of blood flow in the perforating vein of the calf in normal limbs and in those limbs of patients with venous disease under defined laboratory conditions. Both lower limbs of 57 patients, (32 women and 25 men, median age, 56 years; range, 40 to 62 years) were examined by duplex ultrasonography. In 10 patients no clinical or duplex evidence existed of venous disease. In 60 legs we found evidence of superficial venous insufficiency, complicated by lipodermatosclerosis in 29. In 15 limbs we found deep venous insufficiency. Finally, in 19 limbs no evidence existed of venous disease, but venous reflux was present in the contralateral limb. The direction of blood flow in the medial calf perforators was assessed during compression of the foot and calf, by a cuff that inflated to 60 mm Hg. Blood flow was also assessed during deflation of the cuff. We found that the direction of blood flow within medial calf perforators can be both inward or outward, even in limbs without evidence of venous disease. Outward flow could be demonstrated in 21% of perforators in normal limbs. Flow on release of distal compression occurred in 33% to 44% of perforators in limbs with evidence of venous disease but in none of the perforators in limbs without evidence of venous disease. We found that flow, during the relaxation phase, within medial calf perforators was associated with venous disease elsewhere in the limb.

The pathogenesis of skin damage in venous disease: a review.

Venous ulceration remains a major cause of morbidity. Treatment has not improved significantly in recent years, possibly because our understanding of the pathophysiological mechanisms at work is still incomplete. We review the principal abnormalities found in the macro- and microcirculation in this condition and discuss the various theories put forward to explain the mechanism by which skin damage occurs.

Selection of amputation level: A review

Preservation of the knee joint in a patient undergoing lower limb amputation for critical ischaemia is associated with improved postoperative rehabilitation and mobility. Yet, for most surgeons the below-knee to above-knee amputation ratio remains less than one. Poor wound healing and a high reamputation rate for below knee stumps are important factors mitigating against below-knee amputations. Many tests (Doppler indices, segmental pressures, skin blood flow, skin perfusion pressure, TcpO2, thermography) have been described to predict the likelihood of successful healing of an amputation stump but none appears to have gained widespread acceptance. Clinical judgement alone is insufficient to predict the success or failure of an amputation stump. In this review, we have looked at the evidence in support of these tests, particularly those routinely available to most surgeons.

When do vascular surgeons prescribe antiplatelet therapy? Current attitudes

A large number of studies have addressed the efficacy of antiplatelet agents in the prevention of primary and secondary atherosclerotic events. We have undertaken to review the literature and conclude that there is good evidence for the routine prescription of antiplatelet therapy in the prevention of secondary atherosclerotic events in patients with unstable angina, myocardial infarction, transient ischaemic attacks and post-arterial reconstruction. The evidence for any benefit in the prevention of vascular graft occlusion is less clear cut. We therefore conducted a postal survey of Vascular Surgeons in Britain and Ireland, receiving 112 responses to 134 questionnaires. Forty-seven percent of surgeons used antiplatelet therapy following any vascular procedure that they undertook. The rest were more selective in their use of these drugs, reserving them for specific vascular reconstruction, e.g. with synthetic grafts. Five percent of surgeons used anti-platelet aggregating prophylaxis only in patients following transluminal balloon angioplasty. In view of extensive evidence of reduction in long-term vascular mortality and non-fatal vascular events by the use of these drugs in patients who have had a primary vascular event, we would suggest that there is a strong argument for the routine use of anti-platelet drugs in patients presenting with arterial disease to a Vascular Surgeon, regardless of vascular reconstruction, angioplasty or type of graft used.

Is the ‘Normal’ Limb Normal in Unilateral Varicose Veins?:

Objective: To define venous function in the clinically normal limb of patients with unilateral primary varicose veins. Design: Prospective study using duplex scanning and photoplethysmography (PPG) as objective criteria of venous function. Setting: The Middlesex Hospital Vascular Laboratory, a teaching hospital centre of referral for the investigation of venous disease. Patients: Thirty patients with clinical unilateral primary varicose veins. Results: All clinically abnormal limbs had abnormalities on investigation. However, four of 30 patients (13%) also had abnormal duplex findings on the contralateral clinically normal limb, and six (20%) had abnormal PPG refilling times. A total of 26% clinically normal limbs could be demonstrated to have some abnormality of venous function using these two tests. Conclusions: We have shown that the contralateral, clinically normal limb cannot be assumed to be normal without full formal venous assessment.