CONTENTS  •  Volume 10  Number 4 1995

Editorial

Original Articles

132 Venous Reflux at the Sapheno-femoral Junction
G. M. Somjen, J. Don/an, J. Hurse, J. Bartholomew, A. H. Johnston and J. P. Royle

136 Neovascularization In Recurrent Sapheno-femoral Incompetence of Varicose Veins:  Surgical Anatomy and Morphology
G. M. Glass

143 In Vivo Compliance of the Human Saphenous Vein Measured by Sonography:  Comparison with Plethysmographic and In Vitro Measurements
G. Lefthériotis, Th. Pochet, P. Abraham, J. B. Subayi-Kamuanga, A. Jardel and J. L. Saumet

149 ReproducibilIty of Duplex Ultrasound in the Measurement of Venous Reflux
C. J. Evans, G. C. Leng, P. Stonebridge, A. J. Lee, P. L. A/lan and F. G. R. Fowkes

155 Clinical Predictors of the Severity of Chronic Venous Insufficiency of the Lower Umbs: A Multivariate Analysis
L. Mota-Capitão, J. Daniel Menezes and A. Gouveia-Oliveira

160 Diagnosis and Surgical Aspects of Congenital Venous Angiodysplasia in the Extremities
E. Paes and J. Vollmar

165 The Effects of Long Term Graduated Compression Treatment on Venous Function During Pregnancy
C. Austrell, I. Thulin and L. Norgren

Abstracts

Letters

Case Report

173

PD Coleridge Smith

The paper by Glass in this issue considers the questions of whether recurrence at the sapheno-femoral junction (SFJ) is attributable to neovascularization rather than technical inadequacy of the original surgery. Recurrent varicose veins is a frequent problem following long saphenous vein surgery and about 40% of new varices fill from the SFJ, according to recent studies. Are all these the consequence of technical failure to ligate all branches of the SFJ? In a series of 60 patients examined at the Middlesex Hospital before and 3 months after ligation of the SFJ, confirmed to be technically adequate on duplex ultrasonography a further 12 SFJs became incompetent in the next 18 months. Perhaps these could have been due to technical failure in which a very small vein was missed at surgery and on duplex ultrasonography at the three month assessment. Perhaps this subsequently increased in size to produce a recurrence. Some of the SFJ recurrences may be attributable to neovascularization. Glass points out that many of the recurrences involves the original site of ligation suggesting that technical failure is an unlikely cause. It is improbable that a branch on the anterior aspect of the femoral vein close to the sapheno-femoral junction will be missing during dissection of this region. Experience in our own series suggested that complete dissection of the SFJ had been performed, judging from the duplex ultrasound appearances. The appearance of an SFJ which has not been properly dissected are obvious on ultrasound imaging, with preservation of the most proximal valves. To their disgrace, the Annals of the Royal College of Surgeons have recently published a paper suggesting that inadequate exposure to the SFJ promotes safety — protecting the femoral vein [1]. In this manuscript it is suggested that the SFJ should be ligated without opening the superficial fascia. This can only lead to many missed branches and even more recurrences. I doubt if it makes the operation any safer. If the femoral vein is not easily visible during the operation, it may be incorrectly identified and damaged or inadvertently ligated.

I agree with Glass that a proportion of cases of recurrence at the SFJ happen as a consequence of neovascularization. This is a technical failure and should prompt us to consider whether additional measures should be taken to prevent it occurring. In earlier publications Glass has suggested a number of measures that may be taken to prevent the femoral vein re-connecting with superficial varices. These have included ligation using non-absorbable material (silver wire), formal closure of the saphenous opening, and covering the saphenous opening with non-absorbable mesh. Are these methods effective or justified? I welcome letters from readers concerning the paper by Glass commenting on neovascularization and the steps that might be taken to prevent it.

References

1. Annals of the Royal College of Surgeons 1995.

Contents

Venous Reflux at the Sapheno-femoral Junction

G. M. Somjen¹, J. Donlan¹, J. Hurse¹, J. Bartholomew¹, A. H. Johnston¹ and J. P. RoyIe^2
1The Vascular Centre and Vascular Surgery Unit, Mornington Peninsula Hospital, Frankston, Australia; and ²Austin Hospital, Heidelberg, Australia

Objectives: To clarify reflux patterns in the sapheno-femoral junction in legs with varicose veins that display incompetence in the proximal long saphenous vein on duplex scan examination.

Patients and method: One hundred consecutive extremities were selected for ultrasound studies. Venous reflux was examined in the common femoral vein and long saphenous vein at five selected levels in the vicinity of the sapheno-femoral junction.

Results: Duplex ultrasound examination confirmed that in 44 extremities reflux was detectable both in the long saphenous vein and common femoral vein indicating ‘true’ sapheno-femoral incompetence. In 56 legs reflux was limited to the long saphenous vein, whilst the first saphenous valve remained competent. The ultrasound examination suggested that in these cases the reflux originated from the numerous tributaries of the proximal long saphenous vein.

Conclusion: Our findings emphasize the transfascial escape (reflux from the deep veins) is not a necessary precondition of long saphenous vein incompetence and related varicose veins.

Keywords: Duplex ultrasound; Long saphenous vein; Sapheno-femoral junction; Varicose veins: Venous reflux

Correspondence and offprint requests to: George M. Somjen, The Vascular Centre, 1A Vera Street, Frankston, Victoria 3199, Australia.

Contents

G. M. Glass
Varicose Veins Clinic, Mater Hospital, Belfast, UK

Objective: To investigate the surgical anatomy and morphology of recurrent sapheno-femoral incompetence after correctly performed sapheno-femoral ligation. To test the hypothesis that such recurrence develops through neovascularization.

Design: Prospective study of single patient group.

Setting: Varicose vein clinic of teaching hospital.

Patients: One hundred and twenty-eight patients (141 limbs) were reviewed 4 or more years after accurately performed sapheno-femoral ligation with catgut, silk or tantalum wire.

Intervention: Clinical assessment, phlebography, surgical exploration and examination of recurrent veins by radiographic and histological methods.

Main outcome measures: Presence of reflux through newly formed veins at the site of previous ligation.

Results: Of 141 limbs, clinical or phlebographic evidence of sapheno-femoral recurrence was confirmed in 35 of 37 on surgical exploration. The continuity of the saphenous vein with the previously ligated sapheno-femoral junction was restored through a newly formed vein or complex of veins.

Conclusions: Neovascularization was the cause of recurrent sapheno-femoral incompetence after correctly performed sapheno-femoral ligation.

Keywords: Arterio-venous communications; Artificial implant; Neovascularization; Phlebology; Saphenous vein; Varicose vein recurrence; Wound healing

Correspondence and offprint: requests to: G. M. Glass, 22 Castle Street, Strangford, Co. Down BT3O 7NF, UK.

Contents

G. Lefthériotis¹,Th. Pochet^1,2, P. Abraham¹, J. B. Subayi-Kamuanga³, A. Jardel¹ and J. L. Saumet^1
1Departments of Physiology and ³Cardiac Surgery, Medical University of Angers, France; and ²Hemoliege Research Centre, University of Liege, Belgium

Objective: To evaluate a non-invasive and selective measurement of in vivo venous compliance of the human saphenous vein using sonography.

Design: An experimental study in patients prior to coronary bypass surgery.

Setting: Departments of Physiology and Cardiothoracic Surgery, University Hospital of Angers.

Patients: Thirty patients investigated prior to coronary bypass surgery.

Interventions: Simultaneous strain-gauge venous occlusion plethysmography (VOP) and measurements of the circumference of the great saphenous vein by sonography at four different occlusion pressures: 20,30, 40 and 50 mmHg. In 10 of the same patients, in vitro determination of pressure—volume relationship during progressive inflation of excised saphenous vein samples.

Main outcome measures: Venous compliance obtained with the three methods.

Results: Weak correlation coefficients were found between in vitro measurements and VOP (r=0.478, p<0.01) and sonography (r=0.497, p<0.02). Although individual correlations between in vitro and VOP measurements ranged from 0.928 to 0.999, a wide heterogeneity was found with sonography (from 0.620 to 0.985).

Conclusions: Sonography allows the selective measurement of in vivo venous compliance, although the measured compliances differ from other techniques.

Keywords: Compliance; In vitro venous compliance; Saphenous vein; Ultrasound; Venous occlusion plethysmography

Correspondence and offprint: requests to: Dr G. Lefthériotis, Laboratoire de Physiologic, Faculté de Médecine Angers, rue Haute de Reculée, Angers, France.

Contents

C. J. Evans¹, G. C. Leng¹, P. Stonebridge², A. J. Lee¹, P. L. Allan³ and F. G. R. Fowkes^1
1Wolfson Unit for Prevention of Peripheral Vascular Diseases, Medical School, University of Edinburgh, Edinburgh; ²Ninewells Hospital, Dundee; and ³RoyaI Infirmary of Edinburgh, Edinburgh, UK

Design: Repeatability study.

Setting: Vascular clinic in a tertiary referral centre. Participants: Twenty-one patients with severe venous disease.

Interventions: Patients were scanned using duplex ultrasound by two of three observers, then rescanned by a different pair of observers after a mean interval of 51 days.

Main outcome measures: Duration of venous reflux.

Results: On a Wilcoxon signed rank test, observers 2 and 3 showed no significant interobserver variability. The other pairs of observers agreed at the majority of segments, but differed at the popliteal vein (p≤0.001), and superficial femoral and common femoral veins (p≤0.05). Observer 2 showed no significant intraobserver variability, but observer 1 differed at the common femoral and superficial femoral veins (p≤0.05), and observer 3 differed at the short saphenous vein (p≤0.05).

Conclusions: Reproducibility was reasonable at certain sites, but appeared to be influenced by position of the vein.

Keywords: Duplex ultrasonography; Observer variation; Varicose veins; Venous insufficiency; Venous ulcer

Contents

L. Mota-Capitão¹, J. Daniel Menezes¹ and A. Gouveia-Oliveira^2
1Doppler Club de Portugal, Lisbon and ²Department of Biomathematics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal

Introduction: Chronic venous insufficiency (CVI) affects a large proportion of individuals and, with the ageing of the Western European population, its prevalence is bound to increase. Epidemiological data, particularly regarding risk factors, are scarce and controversial.

Objective: Identification of clinical factors associated with an increase in severity of CVI.

Setting: Community-based study of patients presenting to their general practitioner.

Methods: Four hundred and seventy-four unselected patients with symptoms suggesting CVI were evaluated by 18 general practitioners. CVI was diagnosed and assessed by clinical examination and portable continuous-wave Doppler. Severity of CVI was graded according to the nomenclature of the International Society for Cardiovascular Surgery. Patient demographic and clinical factors showing a linear relationship with the severity of CVI were analysed with the proportional odds model to evaluate the simultaneous effect of several factors in the severity of CVI.

Results: A multivariate model is proposed, where age is a major risk factor for increased severity. Other factors that are independently correlated with the severity of CVI are body weight, environmental heat, sedentarity, CVI in both parents, high-dose oestrogen formulations, osteoarticular disease of the lower limbs, presence of truncal varices, involvement of the internal saphena, lymphoedema and history of thrombophlebitis.

Conclusion: Because most studies do not adjust for age when testing for risk factors, this may be an important reason for the multiplicity of reported factors and the lack of consistency of their results.

Keywords: Aetiology; Epidemiology; Risk factors; Varicose veins

Contents

E. Paes and J. Vollmar
Department of Vascular Surgery, Marienhospital, University of Aachen, Aachen, Germany

Objective: An evaluation of the treatment of patients with venous angiodysplasia and ,severe chronic insufficiency.

Design: The clinical series of patients with venous angiodysplasia of Klippel-Trenaunay (K-T) and Servelle-Martorell (S-M) type.

Setting: Primary care teaching hospital.

Patients: Eighty-three patients with angiodysplasia type K-T characterized by the triad of local giantism, varicose veins and naevus flammeus. Malformations of the deep venous system were present in 96%. The predominant vascular lesion in patients with the S-M syndrome (n=34) was a haemangiomatosis, involving both the skeleton and soft tissues, causing growth retardation in the affected extremity. A malformation of the deep venous system could be seen in all patients.

Main outcome measures: Healing of skin ulcers and varicose bleeding of the lower extremities.

Interventions: Conservative treatments included external compression bandages or stockings. In 14 patients, surgical extirpation of superficial veins was used.

Results: All the ulcers were treated successfully, and no haemorrhage reoccurred. Haemodynamic studies showed an improvement of the venous reflux disease in 86% of patients.

Conclusion: Venous angiodysplasia of the lower extremity is nearly always associated with malformation of the deep venous system. Surgery is indicated for the elimination of a pathological short circuit flow in atypical drainage veins of the affected leg, especially when skin lesions are present. For any type of surgery, a careful preoperative angiographic and haemodynamic evaluation is mandatory.

Keywords: Congenital; Extremities; Klippel-Trenaunay syndrome; Servelle-Martorell syndrome; Surgical treatment; Venous angiodysplasia

Contents

C. Austrell, I. Thulin and L. Norgren 
Department of Surgery, Lund University, Lund, Sweden

Objectives: To evaluate venous function during pregnancy and to compare two levels of graduated compression.

Design: Prospective, randomized study.

Setting: Vascular Surgery and Vascular Laboratory, University Hospital.

Patients: Fifty pregnant women using graduated compression with pantyhose stockings exerting either 25 or 13 mmHg ankle pressure. Eight pregnant women acting as controls.

Interventions: Foot volumetry to determine venous function (venous emptying during exercise and reflux) close to week 20, week 33 and post-partum.

Results: The expelled volume increased significantly when graduated compression stockings were used. Refilling flow did not change significantly. Few patients with reflux were found.

Conclusion: Graduated compression stockings of pantyhose type are effective in increasing venous emptying during pregnancy. Stockings exerting an ankle pressure of 13 mmHg at the ankle level were as effective as those exerting 25 mmHg.

Keywords: Compression hosiery; Foot volumetry; Pregnancy; Varicose veins

Contents

Copyright © 2000 Philip Coleridge Smith