CONTENTS • Volume 11 Number 2 1996 |
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Editorial |
43
Varicose Vein Surgery Lars Norgren |
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Original Articles |
45
Standard
Stripping Versus Long Saphenous Vein-Saving Surgery for Primary Varicose
Veins: A Prospective, Randomized Study with the Patients as their own
Controls M. Campanello, J. Hammarsten, C. Forsberg, P. Bernland, 0. Henrikson and J. Jensen 50 Prevalence
and Aetiology of Leg Ulcers in a Defined Population of Industrial Workers 55 Neutrophil
CD11b Expression in Patients with Venous Disease 62 Objective
Quantification of the Continuous-Wave Venous Doppler Examination 68 Laser
Doppler Flux in the Venous Wall 73 Sclerotherapy
for Telangiectasis of the Leg: Results of a 5-Year Follow-up 76 A
Double-Blind Clinical Trial of Hydroxyethylrutosides in the Treatment of
the Symptoms and Signs of Chronic Venous Insufficiency |
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Case Report |
60
Venous Aneurysm of the Upper
Limb C. A. Rogers and J. F. Colin |
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Letters |
83 | |
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Lars Norgren |
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In this issue of Phlebology, Campanello and co-workers confirm the results they first presented in 199() [1] that at a 4-year follow-up the outcome of varicose vein surgery is as good whether the long saphenous vein had been removed or not, as long as a careful high ligation had been performed, and incompetent perforators were ligated. In the first study, patients were randomly allocated to long saphenous vein-saving surgery or stripping, while in the present study patients with symmetrical distribution of their varicose veins were included and patients were used as their own controls, stripping performed on one side only. The most interesting finding in these two studies was that at follow-up the long saphenous vein was found to be patent and most probably useful as an arterial substitute. Reports from 1979 and 1981 [2,3] disagree that the incompetent saphenous vein may he preserved, while another study presents results in line with those from the Swedish studies [4]. The Middlesex group has in two publications shown that long saphenous vein reflux may exist without incompetence of the sapheno-femoral junction [5], and that also after sapheno-femoral ligation, long saphenous reflux existed in a considerable number of patients [6]. Consequently, a randomized study was performed [7] with and without long saphenous vein stripping, and the message was that long saphenous vein reflux was abolished more completely after stripping. It also seemed that remaining long saphenous veins thrombosed to some extent. Why these discrepancies? One possibility is that perforators were taken care of differently. Campanello and Hammarsten emphasize the importance of ligation of all incompetent perforators and they also found more perforators than most other studies have described. This might be a valid explanation, which also takes into account that reflux may he seen in various parts of the long saphenous vein fed by incompetent perforators that were not ligated. It is my understanding that many surgeons, perhaps even a majority, do not take care of perforators to the same extent as the Swedish group finds important. Another question is whether neovascularization has anything to do with recurrence of varicose veins and, most importantly, with recurring reflux in the long saphenous vein. Some evidence exists that neovascularization may contribute to recurrence. Whether this phenomenon differs depending on the surgical technique, e.g. how carefully the groin dissection is performed, could be debated. It is also of importance to note that the studies I refer to above assess patients at very different time points, from 6 months to over 4 years. One would expect that at follow-up after 4 years more reflux would be found if neovascularization had taken place. This was not the case. Technical factors may contribute to these results. The Swedish group uses the technique described by Haeger [8] requiring an incision of no less than 10 cm long in the groin and an extensive dissection of the termination of the long saphenous vein. It is possible that this technique is more ‘preventive’ than a less extensive surgical procedure, which frequently is used to achieve a small scar, to improve the cosmetic appearance. Perhaps these factors contradict each other. There may be two reasons to avoid stripping of the long saphenous vein: one is the (limited) risk of nerve injuries, the other to save a possible arterial conduit for the future. If a saved saphenous vein is not useful, the question is of less importance. However, the Swedish study has shown that most of the veins appear to he useful at follow-up. I do not think that this discussion has come to an end. A key question is the role of the perforators, today more or less neglected by some, maybe overestimated by others. The only conclusion I dare draw is that careful surgical technique is certainly one of the cornerstones in avoiding recurrent or residual varicose veins. References 1. Hammarsten J. Pedersen P. Cederlund C-G, Campanello M. Long saphenous vein saving surgery for varicose veins. A long-term follow-up. Eur J Vasc Surg 1990;4:361-4. 2. Jakobsen BH. The value of different forms of treatment for varicose veins. Br J Surg 1979;66:182-4. 3. Munn SR. Morton JB, Macbeth WAAG, McLeish AR. To strip or not to strip the long saphenous vein? A varicose vein trial. Br J Surg 1981;68:426-8. 4. Woddyer AB, Dormandy JA. Is it. necessary to strip the long saphenous vein? Phlebology 1986;1:221-4. 5. Abu-Own A, Scurr JH. Coleridge Smith PD. Saphenous vein reflux without incompetence at the sapheno-femoral junction. Br J Surg 1994;81:1452-4. 6. McMullin GM, Coleridge Smith PD, Scurr JH. Objective assessment of high ligation without stripping the long saphenous vein. Br J Surg 1991;78: 1139-42. 7. Sarin S, Scurr JH. Coleridge Smith PD. Assessment of stripping the long saphenous vein in the treatment of primary varicose veins. Br J Surg 1992;79:889-93. 8. Haeger K. Technique of high ligation of the long saphenous vein. An analysis of 54 reoperation cases. Acta Chir Scand 1961;122:85—92. |
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Standard
Stripping Versus Long Saphenous Vein-Saving Surgery for Primary Varicose
Veins: A Prospective, Randomized Study with the Patients as their own
Controls
M. Campanello1, J. Hammarsten’, C. Forsberg’, P. Bernland2, 0. Henrikson2 and J. Jensen2 Departments of ‘Surgery and 2Radiology, Varberg Hospital, Varberg, Sweden |
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Objective: To compare the postoperative discomfort and long-term outcome following standard stripping and after long saphenous vein-saving surgery.Design: Prospective, randomized case-control study with patients serving as their own controls. Setting: Department of Surgery, County Hospital, Varberg, Sweden. Patients: Eighteen patients with bilateral primary varicose veins. Interventions: The patients were randomized prospectively to stripping or long saphenous vein-saving surgery. The leg causing most discomfort was operated on first. The other leg was operated on using the alternative method. Main outcome measures: Postoperative discomfort was assessed after an interview with the patient. Long-term outcome was determined by clinical assessment and plethysmographic venous return time. Results: After 4 years the legs subjected to long saphenous vein-saving surgery yielded equal clinical results and had as great a prolongation of the plethysmographic venous return time as legs operated on using standard stripping. More patients reported greater discomfort following stripping than after vein-saving surgery. The saved long saphenous vein in all legs operated on was patent, compressible, non-sclerotic and free of intraluminal echoes. Conclusion: The long-term results of long saphenous vein-saving surgery are as good as standard stripping, provided that incompetent perforators are thoroughly mapped preoperatively and ligated at surgery. Long saphenous vein-saving surgery causes less subjective postoperative discomfort than standard stripping. The saved long saphenous vein can probably be used for future arterial reconstruction. Keywords: Phlebography; Plethysmography; Saphenous veins; Varicose veins; Venous insufficiency; Ultrasonography |
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Correspondence and offprint requests to: Dr Jan Hammarsten, Department of Surgery. Varberg Hospital, S-432 81 Varberg, Sweden. |
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Prevalence
and Aetiology of Leg Ulcers in a Defined Population of Industrial Workers
0. Nelzén1, D. Bergqvist2,
I. Fransson1 and A. Lindhagen1 |
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Objective: To assess leg ulcer prevalence and aetiology in people below retirement age.Design: A validated cross-sectional questionnaire survey. Respondents with a history of leg ulcers were examined. Setting: A defined population of industrial workers. Subjects: All 2785 employees, aged 30—65 years, at the Volvo motor engine factories in Skövde were included. Men predominated (81%) and the median age was 44 years in both men and women. A questionnaire was used to select people with a history of ulceration. A leg ulcer was defined as ‘any wound below the knee (foot ulcers included) that did not heal within a 6-week period after onset of ulceration’. Main outcome measures: Point prevalence of open leg ulcers, overall prevalence of leg ulcer history and aetiological classification. Results: The overall response rate was 87%, and 131 out of 153 subjects with a ‘history of leg ulcers’ were examined (86%). In 98% of positive responders the answers were validated. The overall false-positive response rate was 64. Fifty-four had a true history of ulcers, of whom 16 had open ulcers. Of the latter, 12 were self-caring (75%). Overall venous causation dominated (41%). The ratio of open to healed ulcers was 1:2. The point prevalence for open ulcers was 0.6% and the overall prevalence of ulcer history was 1.6%, if excluding pure traumatic ulcers. The point prevalence was tenfold higher in people aged below 50 years and seven times higher in the age decade 50—59 years if compared with previous estimates based on patients known to health-care professionals. Conclusion: Leg ulcer prevalence has been underestimated in people of working age because they are often self-caring. Since many ulcers have curable causes it is necessary to inform the public of the importance of seeking professional help early. Keywords: Aetiology; Epidemiology; Leg ulcer; Point prevalence; Questionnaire; Venous insufficiency; Work-related |
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Correspondence and offprint requests to: Dr Olle Nclzén, Department of Surgery, Kärnsjukhuset, S—541 85 Skövde, Sweden. |
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Neutrophil
CD11b Expression in Patients with Venous Disease
D. A. Shields1, M. Saharay1, C. Timothy-Antoine2, J. B. Porter2, J. H. Scurr1 and P. D. Coleridge Smith1 Departments of ‘Surgery and 2Haematology, UCLMS, The Middlesex Hospital, London, UK |
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Objective:
To determine whether
neutrophil CD11b, a marker of neutrophil adhesion, differs in patients with
varying degrees of severity of venous disease, and to compare the values
obtained with those of age-matched normal control subjects.
Design: Prospective study, measuring white cell count and neutrophil CD11b expression in whole blood using a fluorescent-labelled monoclonal antibody in a flow cytometer. Setting: The Middlesex Hospital Vascular Laboratory, a referral centre for the investigation of venous disease. Patients: Ten patients with uncomplicated varicose veins, 10 patients with skin changes of lipodermatosclerosis (LDS), and 20 age-matched control subjects with no history or clinical finding of venous disease. Results: Higher levels of CD11b were found in patients with uncomplicated varicose veins compared with their controls (median 4.6 cf. 1.43 for normal controls, p = 0.005, Mann-Whitney U-test, difference between medians 2.7, 95% confidence interval 1 to 4.6), and lower levels in patients with LDS (median 1.22 cf. 1.53 for normal controls, p = 0.028, Mann-Whitney U-test, difference between medians 0.45,95% confidence interval 0.02 to 1.3). There was no difference in the white cell or neutrophil count between the patient and control groups. Conclusions: This study demonstrates increased neutrophil surface CDllb expression in patients with uncomplicated varicose veins, but decreased levels in patients with LDS. This might be due to up-regulation of CD11b in some neutrophils with subsequent adhesion, so that only those with low expression remained in the peripheral circulation. Alternatively, this might represent either down-regulation or chronic exhaustion of neutrophil CD11b in these patients. Keywords: CD11b; Neutrophil adhesion; Venous disease; Venous hypertension; Venous ulceration - aetiology |
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Correspondence and offprint requests to: D. A. Shields. Department of Surgery, UCLMS, The Middlesex Hospital, Mortimer Street, London W1N 8AA, UK. |
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Venous
Aneurysm of the Upper Limb
C. A. Rogers and J. F. Colin Department of General Surgery, Norfolk & Norwich Health Care NHS Trust, Norwich, UK |
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Objective: To
report a case of primary venous aneurysm arising in the antecubital fossa.
Design: Case report. Setting: Department of General Surgery, Norfolk & Norwich Hospital. Norwich. Patient: Patient with clinical and radiological evidence of venous aneurysm. Interventions: Surgical repair. Main outcome measures: Avoidance of pulmonary embolism. Results: Satisfactory post-operative recovery. No complications or subsequent pulmonary embolus. Keywords: Surgery of veins; Vein aneurysm |
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Correspondence and offprint requests to: Mr Colin Rogers, Department of General Surgery, Norfolk & Norwich Health Care NSH Trust, Brunswick Road, Norwich NR1 3SR, UK. |
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Objective Quantification of the Continuous-Wave Venous Doppler Examination T. R. S. Harward1, K. Kraemer2, E. F. Bernstein3 and A. Fronek2 1Section of Vascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida; 2Departments of Surgery & Bioengineering, School of Medicine, University of California, San Diego, La Jolla, California; and 3Division of Cardiothoracic and Vascular Surgery, Scripps Clinic and Research Foundation, La Jolla, California, USA |
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Objective: To develop a quantitative, objective method to diagnose deep venous thrombosis (DVT) with the continuous-wave (CW) Doppler system. Design: Case control study. Setting: Vascular Laboratory of the Surgical Services, Veteran’s Affairs Medical Center, La Jolla, California, USA. Patients, participants: Thirty-five control subjects and the limbs of 50 patients with suspected DVT were examined. Main outcome measures: Phlebography, CW Doppler ultrasound. CW Doppler output was recorded from the popliteal, superficial femoral and common femoral veins. The response to standardized calf compression was analysed. Results: The most useful information included the Doppler velocity increase, decay time and deceleration. Because the determination of decay time does not require calibration of the Doppler system, it is the preferred parameter. Conclusions: A decay time longer than 1.05 s is a very good discriminant between normal control and DVT limbs. Keywords: CW Doppler velocity; Decay time; Deep venous thrombosis; Non-invasive diagnosis |
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| Correspondence and offprint requests to: Dr Arnost Fronek, Department of Surgery — 0643, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093—0643, USA. | ||
| Laser
Doppler Flux in the Venous Wall
G. Belcaro, A. N. Nicolaides, G. Laurora, M. R. Cesarone, M. T. De Sanctis, L. Incande and A. Ricci Microcirculation Laboratory, Chieti University. Chicti, Italy and Irvine Laboratory, St Mary’s Hospital Medical School, London UK |
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Objectives: To evaluate in vivo the perfusion of the venous wall in normal veins, varicose veins and in femoral veins of post-phlebitic limbs recording wall flux with laser Doppler flowmetry. As there is some evidence that both structure and microcirculatory dynamic responses are altered in the abnormal vein wall, we also aimed to study the response of vein wall perfusion to locally induced vasodilatation following papaverine infusion.Design: Open prospective study in patients with venous insufficiency and in patients undergoing coronary revascularization with a normal venous system. Setting: Cardiovascular Institute, Chieti University, Pierangeli Clinic. Italy and Irvine Laboratory, St Mary’s Hospital, London, UK. Patients: Twenty-four normal long saphenous veins and 11 common femoral veins (35 normal veins, 35 subjects) and 42 varicose veins (42 patients). Measurements: Venous wall flux was measured on the external surface of normal long saphenous veins and common femoral veins. Measurements were also made on varicose veins before ligation of the sapheno-femoral junction. All measurements were made when at least three-quarters of the adventitia and periadventitia tissue were still intact for a length of 3 cm. Results: Flux in the normal vein wall was higher (t = 5.88; p<0.05) than in varicose veins and in veins of postphlebitic limbs. There was no difference in flux between varicose veins and post-phlebitic veins. After intravenous papaverine injection in a subgroup or eight normal and eight varicose veins, in the wall of normal veins there was a significant increase in flux (from 8.5 (SD 5.1) units to 13.2 (SD 3.8) units: p<0.05) which was not observed in varicose veins. Conclusions: A higher vein wall perfusion was observed in normal veins compared with varicose veins and postphlebitic limb veins. Greater vascular reactivity to intraluminal papaverine injection was observed in normal veins. Keywords: External valvuloplasty: Laser Doppler; Microcirculation: Post-phlebitic limbs: Varicose veins: Vasa vasorum; Vein walls |
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| Correspondence and offprint requests to: G. Belcaro, Via Vespucci 65.65100 Pescara, Italy. | ||
| Sclerotherapy
for Telangiectasis of the Leg: Results of a 5-Year Follow-up
M. Lucchi, S. Bilancini and S.
Tucci |
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Objective: To evaluate the
recurrence of telangiectases in patients who had previously been treated by
sclero-therapy.
Design: Retrospective single patient group study with 5-year follow-up. Setting: Centro Studi Malattie Vascolari 'J. F. Merlen', Frosinone, Italy. Patients and methods: The records of 52 patients who had been treated by sclerotherapy for leg telangiectases 5 years earlier were reviewed. Patients had been reviewed at yearly intervals. The reappearance of telangiectases at the initial treatment site and at new sites had been recorded at each review. Results: In 77% of patients studied (40/52) new telangiectases appeared. Of these, 67% (35/72) were in a different area and 56% (29/52) were in the same area (X2= N.S.). In 46% of cases (24/52) telangiectases occurred both in the area treated originally and in additional areas. In 48% of cases affected by a recurrence (19/40), the additional telangiectases were of minimal extent requiring little if any treatment. Conclusions: Sclerotherapy of telangiectases treats the consequences of the disease and does not address the cause. Consequently, patients often suffer recurrence of their telangiectases. This may be regarded as an evolution of the disease, affecting new veins, rather than true recurrence. Maintenance treatment will often be required to sustain the results following the initial course of sclerotherapy. Keywords:Sclerotherapy; Telangiectases |
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| Correspondence and offprint requests to: M. Lucchi, Centro Studi Malattie Vascolari 'J. F. Merlen', Via Mola Vecchia 2, 03100 Frosinone, Italy. | ||
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A
Double-Blind Clinical Trial of Hydroxyethylrutosides in the Treatment of the
Symptoms and Signs of Chronic Venous Insufficiency
M. Cloarec1, R. Clement2 and P. Griton3 1Department of Angiology, CHU PARIS VI-Medicine, Hôpital Tenon, Paris; 2Department of Angiology, Hôpital Begin, Saint-Mandé; and 320, boulevard de Courcelles, Paris, France |
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Objective: To study the safety and efficacy of hydroxyethylrutosides (HR) in patients with chronic venous insufficiency (CVI) (Widmer grade II) and examine any correlation with objective measurements (plethysmography and TcPo2).Design: Double-blind, randomized, placebo-controlled, multicentre trial. Setting: One outpatient university angiology clinic, one outpatient angiology clinic in a military hospital and one private angiological consultation, all in the Paris area. Patients: One hundred and nine patients with grade II Widmer CVI, confirmed by echo-Doppler and plethysmography. Elastic stockings were excluded. After five exclusions, 53 received HR and 51 placebo. Interventions: Patients randomized to one sachet of 1 g HR twice daily (or placebo) for 2 months, after a 1 month placebo run-in period. Examinations on entry to the trial (T-1), after 1 month run-in (T-0) and after 1 (T+1) and 2 months (T+2) treatment. Main outcome measures: These were measured at each of the four visits. Primary outcome: minimal ankle and maximal calf circumferences. Secondary outcomes: five individual leg symptoms and total symptom score, pitting oedema. Plethysmography (six calculated variables) and TcPo2. Results: The reduction of both ankle and calf circumferences was significantly greater in the HR group (p<0.0001), as was pitting oedema (p<0.001), the five individual symptoms and the total symptom score (p<0.001). Of the plethysmographic findings, there was a significant reduction in maximum venous outflow (,p<0.001at T±1 and p<0.005at T+2). Overall there was no significant change in TcPo2. Conclusions: HR is an effective and well-tolerated treatment for leg oedema and symptoms of patients with CVI. Keywords: Chronic venous insufficiency; Hydroxyethylrutosides; Leg circumference; Leg symptoms; Plethysmography; TcPo2 |
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| Correspondence and offprint requests to: Professor M. Cloarec, CHU PARIS VI-Medicine, Hópital Tenon, 4, rue de Ia Chine, 75020 Paris, France. | ||
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Send e-mail to p.coleridgesmith@ucl.ac.uk
Copyright © 2000 Philip Coleridge Smith
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