Phlebology: The Journal of Venous Disease

A review of the published data on epidemiology, pathophysiology, diagnostic techniques and prevention of the post-thrombotic syndrome (PTS).

Studies, published between 1966 and 1996, identified through the medline database, and references cited in identified articles were included.

Deep venous thrombosis (DVT) may cause outflow obstruction and valve incompetence, resulting in venous hypertension. PTS is probably the effect of venous hypertension on the microcirculation. For qualitative anatomical and functional assessment of the venous system, duplex scanning is required, and for quantitative functional assessment, plethysmographic methods are the most suitable. The best treatment of PTS is its prevention by optimizing diagnosis and treatment of DVT and by prescribing and wearing elastic compression stockings. Until valid follow-up studies have been performed, distal DVT should not be neglected when assessing the PTS risk.

PTS is a serious problem in terms of prevalence, complications (venous ulcers) and treatment with considerable socio-economic consequences. Duplex and plethysmography are valuable tools in its diagnosis and might be appropriate to identify patients at risk of developing PTS.

To assess the effect of varicose vein surgery on the venous function of the lower limb and to determine the ability of strain-gauge and photoplethysmography in discriminating between normal and abnormal venous function.

Prospective randomized trial with follow-up to 1 month postoperatively.

Fifteen patients presenting for varicose vein surgery and 10 controls with no evidence of venous insufficiency.

Venous investigations were carried out preoperatively and at 1 month postoperative appointments.

The effect of varicose vein surgery on lower limb venous function and the ability of plethysmography to distinguish normal from abnormal venous function.

Significant differences were found between pre- and postoperative venous refilling times (VRT) in patients attending for varicose vein surgery (p><0.01). Significant differences were also found between control and case preoperative VRTs. No significant differences were found between pre- and postoperative, and case/control venous outflow (VO) and venous capacitance (VC) values.

Varicose vein surgery improved the venous function in all of the lower limbs investigated. Photoplethysmographic venous refilling times were found to be a useful, reproducible measure, able to distinguish normal from abnormal venous function.

Evaluation of the feasibility and utility of haemodynamic correction of primary varicose veins (French acronym: CHIVA).

Prospective, single patient group study.

Department of Surgery, University of Ferrara, Italy (teaching hospital).

Fifty-five patients with primary varicose veins and a normal deep venous system (ultrasonographic criteria) were studied.

Fifty-five haemodynamic corrections by the CHIVA method described by Franceschi were undertaken. Seven patients were treated for short saphenous vein varices (group A) while 48 patients were treated for long saphenous vein varices (group B).

Clinical: presence of varices and reduction in symptoms. Duplex and continuous-wave Doppler detection of re-entry through the perforators and identification of recurrences or new sites of reflux. Postoperative ambulatory venous pressure and refilling time measurements. Patients were studied for 3 years following surgery.

In group A, 57% short saphenous vein occlusions with no re-entry through the gastrocnemius and soleal veins were recorded. In group B the long saphenous vein thrombosis rate was 10%. In this group 15% of the patients showed persistence of reflux instead of re-entry at the perforators. Early recurrences were also observed. Overall CHIVA gave excellent results in 78% of the patients. Statistically significant ambulatory venous pressure and refilling time changes were recorded (p<0.001).

CHIVA treatment is inadvisable for short saphenous vein varices. Long saphenous vein postoperative thrombosis is related to development of recurrences

To study the mechanisms by which haemodynamic function improves following long saphenous vein-saving surgery.

Cohort study.

Twenty patients, 14 women and six men, with primary varicose veins.

Varicose vein surgery by the long saphenous vein-saving technique.

Preoperative investigation by physical examination, strain-gauge plethysmography, phlebography and measurements of the long saphenous vein diameter at four different locations using high-resolution, real-time ultrasound. Three months following vein-saving surgery, the patients were reassessed with physical examination, strain-gauge plethysmography and measurements of the long saphenous vein diameter.

All patients but one showed excellent or good results following surgery. The preoperative diameter of the long saphenous vein was reduced by 40% at four different levels in the operated legs (p<0.01). The venous return time of the same legs increased 2.4 times (p<0.001). The decrease of the long saphenous vein diameter correlated positively with the increase in venous return time (t-50), (r=0.50, p=0.04).

The results suggest that the development of incompetent perforators is an early major event in the formation of primary varicose veins. The results also suggest that the long saphenous vein valvular incompetence in varicose veins is attributable to venous wall dilatation rather than degeneration of the valves. The results support the hypothesis that the improvement in haemodynamic function following long saphenous vein-saving surgery is due, at least partly, to a reduction of the long saphenous vein diameter, which in turn tends to restore valvular competence.

Treatment of benign venous strictures with the Wallstent endoprosthesis.

A retrospective study of a patient group with benign venous strictures.

Departments of Radiology and Surgery in a London teaching hospital.

Three patients with clinically significant benign venous strictures.

Successful placement of the Wallstent endoprosthesis following failed angioplasty.

Maintained clinical stent patency at follow-up.

All patients reported a good symptomatic improvement and this was confirmed by reduction in swelling of the affected limb on clinical examination Doppler examination in one case confirmed stent patency at 1 year.

The role of the Wallstent endoprosthesis in the treatment of benign venous strictures deserves evaluation by prospective study. The successful outcome in the three patients reported indicates its clinical application.

To determine if a limited regimen of sequential gradient intermittent pneumatic compression (‘HomeRx’: HRx) is as effective in promoting the healing of chronic venous stasis ulcers as is the Unna's boot (UB), considered the ‘gold standard’ in compression therapy.

Fifty-three patients, aged 31–85 years, with ulcers ranging up to 31.8 cm² (mean 9.9, SE 1.1) were Prospectively randomized to treatments with UB or HRx and followed weekly for 180 days or until healing was complete, whichever came first. The HRx group wore graduated compression stockings, which were removed only while intermittent pneumatic compression was applied bilaterally at home for 1 h each morning and 2 h each evening. The UB was re-applied at least weekly. The two groups were equivalent in their use of hydrocolloid dressings and periods of leg elevation.

Therapy performed at home, with weekly visits to an outpatient clinic.

Complete ulcer healing and the rate of healing, based on area and perimeter changes; amounts of wound exudate and pain.

Complete healing was achieved in 20 of 28 Patients (71%) in the HRx group, compared with 15 of 25 (60%) treated with UB. Three patients had an adverse reaction to UB, one had cellulitis and five were non-compliant. Correcting for these withdrawn patients by life table analysis, healing rates were 76% and 64%, respectively. Healing rates did not correlate with haemodynamic measurements made prior to treatment.

Using HRx for just a few hours daily to supplement graduated elastic compression heals venous ulcers at least as well as does the UB, without its disadvantages (e.g. the need for frequent re-application by qualified personnel, difficulty bathing), affording patients greater convenience during treatment.

To investigate microcirculatory functional abnormalities in non-ulcerated limbs with chronic venous insufficiency (CVI).

A case-control study.

Outpatient clinic of a university hospital.

Laser-Doppler was used to evaluate skin blood flow and the veno-arteriolar response (VAR) in 12 limbs with perimalleolar oedema and venous dilatation (CVI stage I), 12 with lipodermatosclerosis and hyperpigmentation (CVI stage II) and 12 healthy limbs. Resting flow (RF), blood volume and velocity were evaluated with the patient supine. After 2 min in the sitting position, blood flow (SF) was determined and the VAR was calculated.

Compared with controls, blood volume was significantly increased and velocity reduced (p<0.05) in both groups; RF and SF were significantly increased (p<0.05) and the VAR was significantly reduced in stage II CVI patients.

Venous microangiopathy and impaired orthostatic reactivity, as indicated by the alteration in the VAR, are present in non-ulcerated limbs with CVI.

To use duplex ultrasound scanning to determine the frequency of reflux in crural veins and its relation to the presentation, reflux in superficial and other deep veins, and outward flow in perforators in patients referred for assessment of chronic venous disease.

Scanning of superficial, deep and perforator veins.

A vascular diagnostic laboratory in Melbourne, Australia.

A study of 2590 lower limbs in 1684 consecutive patients.

The frequency of reflux in crural veins.

The posterior tibial, anterior tibial and peroneal veins were identified in 98%, 95% and 95% and reflux was observed in 5%, 2% and 3%, respectively. Posterior tibial reflux was twice as frequent as reflux in the anterior tibial and/or peroneal veins alone. Posterior tibial reflux was significantly more frequent if there were clinical complications (19% of limbs with previous ulceration or lipodermatosclerosis), short saphenous reflux alone (8%) or both long and short saphenous reflux (11%), popliteal reflux (28%), or outward flow in medial calf perforators (6%) (p<0.0001 for each). Posterior tibial reflux was no more frequent if there was Jong saphenous reflux alone or femoral reflux alone. Anterior tibial and/or peroneal reflux without posterior tibial reflux was not significantly related to the clinical presentation or reflux at any other site.

The association of posterior tibial reflux with clinical complications, short saphenous reflux (alone or associated with long saphenous reflux), popliteal reflux or outward flow in perforators observed with duplex scanning contrasted with the lack of any such associations for anterior tibial or peroneal reflux without posterior tibial reflux. Scanning the anterior tibial and peroneal veins may add little to the examination.

To use duplex ultrasound scanning to compare limbs with recurrent and primary varicose veins and to identify connections between deep veins and recurrences.

A non-invasive vascular laboratory in Melbourne, Australia.

A study of 779 limbs with recurrent varicose veins previously treated by ligation or stripping of the long saphenous vein and 1521 limbs with primary varicose veins.

Connections between deep veins and recurrent varices, reflux in superficial and deep veins, and outward flow in perforators as demonstrated by duplex ultrasonography.

Recurrence was due to reflux in the long saphenous territory in 71.8%, short saphenous reflux alone in 14.7% or outward flow in calf perforators without saphenous reflux in 5.2%, while no source was detected in 8.3%. Limbs with recurrent veins in the long saphenous territory were compared with limbs with primary varicose veins; there was more frequent outward flow in thigh perforators (25.2% vs. 16.2%) but no difference for deep reflux (20.7% vs. 17.5%) or outward flow in calf perforators (56.8% vs. 53.1%). The source for recurrence in the long saphenous territory was from a single large connection in the groin in 46.3%, multiple smaller proximal connections in a further 46.3%, or thigh perforators in 7.4%. The destination was to an intact long saphenous vein in 33.7%, major tributaries in 28.7% or to other varices in 37.6%. Limbs known to have been treated by long saphenous ligation alone were compared with those known to be treated by long saphenous ligation and stripping; the source was more likely to be from a single large vein in the groin (60.3% vs. 39.9%) and the destination was more likely to be an intact long saphenous vein or major tributary (75.0% vs. 55.2%).

Duplex ultrasound scanning detected the source of recurrent varicose veins in over 90% of patients and demonstrated whether there were single large or multiple smaller connections in the veins affected, and this helps to select the most appropriate treatment. Recurrence after stripping the long saphenous vein was more likely to be due to multiple small connections passing to scattered varices and this may allow more simple treatment by injection sclerotherapy rather than repeat surgery.

Case report.

University Hospital of Copenhagen.

One patient presenting with venous ulceration of the leg after recurrent episodes of deep vein thrombosis which started at the age of 15 years.

Oral anticoagulation treatment and standard management of leg ulceration.

Protein C, protein S and anti-thrombin III plasma levels were measured in the patient and her asymptomatic sister.

Plasma protein S levels were reduced in the index patient and her sister.

We suggest that patients with venous leg ulcers attributable to post-thrombotic syndrome are investigated for abnormalities of the coagulation system.