CONTENTS  •  Volume 10  Number 3 1995

This issue of Phlebology is published to mark the 12th World Congress of the International Union of Phlebology held at the Barbican Centre in London. For delegates of the Congress it is accompanied by a supplement comprising the proceedings of this meeting. The editors of these volumes believe that their contents reflect the current state of the art in venous research, and include laboratory based studies, clinical series and the personal observations of phlebologists world-wide. I believe that the value of such a collection of articles is that it presents a snapshot of thinking in a wide range of fields, indicating the interests of venous research groups around the world. Clearly the value of this collection of papers is greatly enhanced for those attending the meeting, who have the opportunity to discuss methodology, mechanisms and interpretation of data with the authors. May I wish all of those attending the Congress in London an interesting, informative and enjoyable stay.

This issue of Phlebology also reflects an international view of this subject area, in keeping with the stated aims of the journal. A number of authors report their findings in different aspects of venous disease studied using colour duplex ultrasonography. I have previously recommended this as the method of choice when investigating patients with venous disease in view of the sensitivity of this technique to blood flow and the non-invasive nature of the investigation. However, duplex ultrasonography provides much more functional information than that formerly afforded by phlebography. The main difficulty seems to lie in interpretation of these data. For example, it is possible to identify calf vein incompetence (deep vein) in patients with symptoms of chronic venous insufficiency, which may occur in isolation or with associated popliteal and femoral vein incompetence. This question is difficult to answer, since carefully conducted studies comparing clinical and duplex ultrasound findings are few in number.

Another paradox shown in an article published in this issue of Phlebology (Guex et al) is that a substantial proportion of patients with primary varices appear to have incompetent long saphenous veins and competent sapheno-femoral junctions. This report confirms the observations of other investigators. The source of the long saphenous vein reflux is suggested by different authors to arise from thigh perforating veins, the superficial epigastric vein, or tributaries of the long saphenous vein. Except for the thigh perforating veins, orthograde flow in presumably normal veins permits reverse flow in the long saphenous vein. Under these circumstances, it is unlikely that SFJ ligation alone will prevent long saphenous vein reflux. This adds support to one of my previously published observations that long saphenous vein reflux continues in half the patients with long saphenous varices in whom the sapheno-femoral junction was ligated without stripping the long saphenous vein.

Another paper discusses recurrent varices (Guarnera et al) and the association of deep vein incompetence. Duplex ultrasonography reveals a wide range of expected and unexpected findings in patients with recurrent varicose veins. The questions are, which should be operated upon, which treated by sclerotherapy and which are best left untreated? The over-ambitious surgeon may be tempted to make large incisions in the leg to retrieve small varices with poor cosmetic outcome. Injudicious re-exploration of the sapheno-femoral or sapheno-popliteal junction may lead to little advantage and expose the patient to the hazards of severe venous, arterial or neurological injury.

Design: Observational study of saphenous vein morphology.

Setting: Departments of Surgery and Pathology, Leicester Royal Infirmary.

Patients: Sixty vein biopsies from patients undergoing arterial surgery.

Main outcome measures: Intimal and medial thickness and morphology.

Results: Smooth muscle cell hyperplasia, elastosis and fibrosis contributed to intimal thickening (> 10 um) in 87% of veins. This was frequently associated with medial longitudinal muscle hypertrophy. Intimal thickness had a skewed distribution with a median (range) of 33 (8-381) um. The upper limit of the normal range was 200 um. The median (range) medial thickness was 293 (131-468)um.

Conclusions: Intimal thickening is common in the long saphenous vein of patients undergoing arterial surgery but is extensive in only a small proportion. The upper limit of the normal range was 200 um.

Methods: We performed clinical examination and duplex scanning of 498 lower limbs in 317 patients with obvious varicose veins for whom no previous treatment had been undertaken.

Results: Classes of chronic venous insufficiency (CV I) in 498 legs: grade 0: 117 (23.5%); gr 1: 310 (62.2%); gr 2: 47 (9.4%); gr 3: 24 (4.8%). Duplex-detected venous reflux was found in the greater saphenous vein territory (junction or trunk or related perforator or main tributary) in 423 limbs (85.3%) the sapheno-femoral junction was incompetent in only 342 legs (68.7%). Reflux was found in the lesser saphenous vein territory in 1(X) limbs (20.1%) and in sapheno-popliteal junction in 92 (18.5%). Strictly non saphenous origin of varicosities was found in 31 limbs (6.2%). Deep venous incompetence was found in 48 legs (9.6%).

Conclusions: These findings yield data on the distribution and occurrence of lower limbs venous lesions in patients with varicose disease.

Design: Retrospective analysis of patients affected by RVV submitted to clinical examination, continuous-wave (CW) Doppler, duplex scanning and descending phlebography in cases of incompetence at groin level.

Setting: Department of Vascular Surgery, Istituto Dermopatico dell’Immacolata (IRCCS), Rome.

Patients: Two hundred and thirty-nine patients affected by RVV.

Main outcome measures: CW Doppler ultrasound, duplex ultrasound imaging and descending phlebography to assess venous incompetence.

Results: Doppler examination revealed no reflux at the groin level in 80 limbs. In the remaining 166 limbs, descending phlebography showed a superficial venous reflux in 95 limbs (related to a sapheno-femoral junction recanalization or to an inadequate previous operation) while in 69 (28% of the 246 limbs examined) deep venous reflux was present (superficial femoral vein in 38 cases, profunda femoris vein in seven cases and both veins in 24 cases); in two cases reflux came from the pelvic veins.

Conclusions: Our data suggest a possible role of primary deep venous insufficiency in the development of RVV and the value of descending phlebography in the plan-fling of further surgery.

Setting: District General Hospital.

Patients: One hundred and sixty-eight new patients and a separate group of 100 patients having a day case varicose vein operation.

Interventions: New patients were assessed according to RCS guidelines. Postoperatively, patients completed a one-page questionnaire.

Results: Of the 168 patients, 141 (84%) were suitable for a day case operation. The main indications for an overnight stay were associated medical conditions and social problems. Of the 100 patients having an operation, 90 stated they would have a similar procedure carried out as a day case again. In the first 2 postoperative weeks, 12 patients saw their GP and three a district nurse. No patients contacted their GP before the fifth postoperative day. Twenty-eight patients took no analgesia following discharge from hospital; 81 felt that their postoperative pain was less than or as they expected.

Conclusion: Most patients with varicose veins are suitable to have a day case procedure, which is well tolerated and provides no additional workload for the GP.

Design: A retrospective questionnaire study involving 70 patients with DVT, verified by phlebography 5 and 10 years earlier.

Setting: Tampere University Hospital, Finland.

Patients: Seventy out of 86 patients who had suffered a definite DVT answered a questionnaire on subjective symptoms and visits to health care organizations.

Interventions: All 70 patients were treated initially with heparin and warfarin after the DVT was diagnosed.

Main outcome measures: The frequency of late symptoms in the leg with DVT. The relation of the site of the acute DVT to late sequelae.

Results: The frequency of asymptomatic patients was only 13%. Typical symptoms were evening pain, oedema and pigmentation. There were no differences between calf DVTs and more proximal DVTs in respect of the late symptoms. All patients with recurrent DVT were symptomatic.

Conclusions: The late sequelae of DVT are common and necessitate a considerable number of visits to health care centres. Calf DVTs seem to cause late symptoms as often as more proximal DVTs.

Design: Single patient group study comparing techniques.

Setting: Teaching hospital vascular laboratory.

Patients: Two hundred patients (265 legs) referred to St Mary’s Hospital Vascular Laboratory for preoperative

varicose vein marking.

Methods: Patients were studied using LCT and duplex ultrasonography to identify calf perforating veins.

Results: In part 1 of the study LCT identified 47 ‘areas at risk’, 42 of which were demonstrated to contain incompetent perforating veins on duplex examination (positive predictive value 89%). Thirty-eight of these 42 patients were explored at operation and 36 (95%) were confirmed as incompetent. The remaining two perforating veins could not be located. In part II of the study LCT identified 327 ‘areas at risk’, 299 of which were demonstrated to contain incompetent perforating veins on duplex examination (positive predictive value 91%).

Conclusion: LCT is useful in the identification of incompetent perforating veins, it is easy to perform, less time consuming, cheaper and can replace duplex scanning.

Design: In vivo and in vitro animal study.

Setting: University Department of Physiology.

Materials: Segments of canine vein were perfused in vitro (n = 84) and in situ (n = 60).

Main outcome measures: Specimens were studied by conventional histology using light microscopy.

Results: Radial reflux caused dilatation of constricted segments and when associated with turbulent flow resulted in the formation of acute short-lived varices, marked dilatation of sinusoidal venules at the medioadventitial junction of the segments and of sinusoidal venules in the paradventitial tissue.

Conclusion: During laminar flow radial reflux operated as a feedback to regulate venoconstrictor tone. During turbulent flow it caused more widespread vascular changes and inhibited adrenergic activity. The changes are of particular interest because they mimicked those that characterize the early stage of varicose veins.