CONTENTS • Volume 11 Number 4 1996 |
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Editorial |
135
Calf
Perforating Veins - Time for an Objective Appraisal? P. D. Coleridge Smith |
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Original Articles |
137
The
Effect of Probe Position, Calf Muscle Function and Lipodermatosclerosis on
Photoplethysmographic Venous Refilling Time P. Rashid, M. C. Stacey, S. E. Hoskin and C. A. Pearce 141 The
Effect of Graduated Compression Stockings on Lower Limb Venous
Haemodynamics 146 Laser
Doppler Flux in Normal and Varicose Long Saphenous Vein Wall |
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Case Report |
150
The
Use of Intermittent Pneumatic Calf Compression in Isolated Femoral Vein
Reconstruction A. Qureshi, N. Roberts and A. R. Wilkinson |
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Meeting Report |
153
Joint Meeting of the Venous Forum of the Royal Society of Medicine and
Societas Phlebologica Scandinavica, Snekkersten, Denmark, 30 May-1 June
1996 C. R. R. Corbett |
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Abstracts |
156
Joint Meeting of the Venous Forum of the Royal Society of Medicine and
Societas Phlebologica Scandinavica, Snekkersten, Denmark, 30 May-1 June
1996
163 The Venous Forum of The Royal Society of Medicine, Midland Hotel, Manchester, 11 October 1996 |
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Book Review |
172 | |
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Letters |
173 | |
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Calf Perforating Veins - Time for an Objective Appraisal? PD Coleridge Smith |
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There is growing enthusiasm for sub-fascial endoscopic perforator surgery (SEPS). This may have originated from the success of intra-abdominal surgery performed using endoscopic methods and appears to have been led from Germany where a large number of patients have undergone these procedures. However, I remain uncertain as to whether the world literature in this area justifies increased surgical treatment of the perforating veins. The history of perforating vein ligation is discouraging and there has been little convincing evidence that these veins actually cause venous ulceration. Certainly Cockett in his 1953 paper showed the association between leg ulcers and perforating veins. But this was an observational study and the evidence described in this paper does not show a causal relationship. Much of the subsequent literature has shown widely differing results following treatment. In many instances, superficial venous surgery was combined with perforating vein surgery, obscuring the effect of the perforating vein surgery alone. When perforating vein surgery was carried out in patients with a history of venous ulceration in whom there was phlebographically documented evidence of post-thrombotic deep vein damage, all of the ulcers recurred [1]. In a subsequent series of similar patients studied prospectively, no improvement in functional indices was shown following perforating vein surgery [2]. From these data it must be concluded that perforating vein surgery is probably inappropriate in patients with deep vein incompetence. An intriguing study has been published in the pages of Phlebology in which patients with varicose veins were treated both by perforator ligation and by saphenous vein stripping [3]. An interval of at least 3 months between procedures was allowed during which the functional outcome was assessed by foot volumetry. No improvement could be shown to be attributable to the perforating vein ligation. Considerable improvement was found after saphenous vein stripping. It is clear from a recent series of studies in which duplex ultrasonography has been used to evaluate patients with venous leg ulcers, that a large proportion of these patients have superficial venous incompetence alone, combined with perforating vein incompetence in some. At recent meetings of the Venous Forum of the Royal Society of Medicine (reported in the abstracts included in this issue) it has been shown that sapheno-femoral ligation may be sufficient to achieve ulcer healing in these patients. Although the use of superficial venous surgery to heal venous ulcers is by no means a new treatment, these studies confirm that duplex ultrasonography identifies a group of leg ulcer patients who may benefit considerably from surgery. But should they also undergo perforating vein ligation? Endoscopic surgery is very appealing, in that it minimises the trauma to the patient of surgical procedures. However, experience from its use in cholecystectomy shows that major complications may ensue when it is used without proper training and skill. Popliteal vein ligation was recommended by Bauer in Sweden and Linton in the USA, as treatments for deep vein incompetence. Unfortunately the outcome of this procedure was very poor and this was quietly dropped from the surgical repertoire. Later, perforating vein ligation was popularised by Linton and Cockett, but again many patients with venous ulceration suffered poor healing of the calf incision after these operations, perhaps without significant clinical benefit. In order to avoid repeating the errors of previous treatments, it seems advisable to objectively assess SEPS in a more objective manner. We now have much better methods of studying the anatomy and function of the venous system of the lower limbs than was available when calf perforating vein ligation was first popularised. I believe that it is essential to conduct a study in which both the clinical outcome and functional results of perforating vein ligation are studied in an objective manner. This could not be done by a single centre in a short space of time, but really requires a multi-centre study. Fortunately Professor Vaughan Ruckley from Edinburgh has begun organising just such a study with his usual energy. The outcome of this will hopefully light the way in determining the future of surgical interventions in patients with chronic venous disease leading to leg ulceration. References 1.Burnand K, Thomas ML, O’Donnell T, Browse NL. Relation between postphlebitic changes in the deep veins and results of surgical treatment of venous ulcers. Lancet 1976;i:936-8. 2.Stacey MC, Burnand KG, Layer GT. Pattison M. Calf pump function in patients with healed venous ulcers is not improved by surgery to the communicating veins or by elastic stockings. Br J Surg 1988;75:43&-9. 3.Akesson H. Brudin, L. Cwikel W, Ohlin P, Plate 0. Does the correction of insufficient superficial and perforating veins improve venous function in patients with deep venous insufficiency? Phlebology 1990:5:113—23. |
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The
Effect of Probe Position, Calf Muscle Function and Lipodermatosclerosis on
Photoplethysmographic Venous Refilling Time
P. Rashid, M. C.
Stacey. S. E. Hoskin and C. A. Pearce |
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Objective:
To assess the
influence of probe position, lipodermatosclerosis and method pf calf muscle
emptying on the venous refilling time as measured by photoplethysmography in
both normal limbs and limbs with chronic venous disease.
Design: Prospective evaluation of age- and sex-matched control and study groups. Setting: University Department of Surgery, Vascular Research Laboratory, Fremantle Hospital, Western Australia. Patients: There were 38 controls and 31 patients with venous ulceration. Interventions: Venous refilling times were measured in six positions on the leg in all subjects: the foot, 5 cm below medial tibial condyle in the upper calf, and in the gaiter region on the medial, lateral, anterior and posterior positions at 7.5 cm above the medial malleolus. Measurements were undertaken on active exercise and after bimanual calf compression in the medial gaiter region. Measurements were also undertaken in areas of lipodermatosclerotic skin and in normal-appearing adjacent skin. Results: In normal legs, the lowest refilling times were in the anterior and lateral gaiter positions. Venous patients had a shorter refilling time in the dorsal foot, medial gaiter, posterior gaiter and medial below-knee positions, when compared with controls (Mann-Whitney U-test, p<0.01). The shortest refilling time in patients with venous disease was in the medial gaiter region. Refilling time was slightly prolonged over lipodermatosclerotic skin compared with adjacent normal-looking skin. Refilling time measured after passive emptying of the calf muscle by external compression was significantly prolonged compared with calf emptying by active calf compression (p<0.0l). This change was similar for both groups. Conclusions: When using venous refilling time on photoplethysmography to distinguish venous from normal limbs, the best separation is in the medial gaiter position. If other probe sites or methods of calf emptying are to be employed, it is imperative that individual laboratory normal ranges be established for the particular method being employed. Keywords: Chronic venous disease; Photophlethysmography; Vascular investigations; Venous refilling time |
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| Correspondence and offprint: requests to: Assoc. Professor M. C. Stacey, University Department of Surgery, Fremantle Hospital, P0 Box 480, Fremantle, Western Australia 6160, Australia. | ||
| The
Effect of Graduated Compression Stockings on Lower Limb Venous
Haemodynamics
E. A. Cooke, T.
Benkö, B. M. O’Connell, M. A. McNally and R. A. B. Mollan |
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Objectives:
To compare the
effect of four types of thigh-length graduated compression stockings (GCS)
on lower limb venous blood flow using strain-gauge plethysmography (SOP).
Design: A randomized controlled study. Setting: Inpatient Orthopaedic Centre. Patients: 200 preoperative patients admitted for elective lower limb orthopaedic surgery. Interventions: Patients were randomized to five groups to wear one of four types of GCS or no stocking (control). Resting venous flow parameters were measured prior to application of GCS and after 20 mm bed rest with the stockings in situ. Main outcome measures: Effects on resting venous capacitance (Vc) and venous outflow (Vo). Results: In the control group 20 mm bed rest had no effect on the parameters studied. Both Vc and Vo were significantly increased (p<0.001) in all the groups wearing stockings. There was a significant variation in the changes in outflow produced by the different stocking types (p<0.05). Conclusions: GCS have a beneficial effect on lower limb venous outflow, preventing venous stasis, an important factor in the development of deep venous thrombosis. This effect varies depending on which type of stocking is used. Keywords: Bed rest; Compression stockings; Patient compliance; Plethysmography; Stasis; Thromboembolism |
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Correspondence and offprint requests to: E. A. Cooke, Department of Orthopaedic Surgery, The Queen’s University of Belfast, Musgrave Park Hospital, Belfast BT9 7JB, UK. |
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| Laser
Doppler Flux in Normal and Varicose Long Saphenous Vein Wall
A. Taccoen1,
C. Lebard2 and F. Zuccarelli3 |
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Objective: To assess the wall perfusion in normal and varicose veins. Design: Observational study. Setting: Departments of vascular surgery of private and public hospitals. Patients: Twenty-seven patients undergoing vein surgery (43 long saphenous veins) and eight controls operated on for femoral-popliteal bypass. Methods: Laser Doppler flowmetry assessing long saphenous vein wall perfusion 3 cm below the sapheno-femoral junction. Results: Significantly reduced wall perfusion was shown in varicose long saphenous veins compared with normal veins: 16.3 (SD 10.3) versus 45.4 (SD 14.9); p<0.001. Conclusion: Our data suggest a primary or secondary role for lower perfusion within the vein wall in varicose veins. Keywords: Laser Doppler; Varicose veins; Vasa vasorum, Wall perfusion |
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| Correspondence and offprint requests to: Dr A. Taccoen, Scientific Manager, Negma Research, Avenue de I’Europe, Toussus Ic Noble, 78771 Magny les Hameaux, France. | ||
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The
Use of Intermittent Pneumatic Calf Compression in Isolated Femoral Vein
Reconstruction
A. Qureshi, N.
Roberts and A. R. Wilkinson |
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Objective: To
report two cases of isolated femoral vein injury reconstruction and a review
of the literature.
Design: Case report. Setting: Hull Royal Infirmary, Kingston Upon Hull. Patients: Two patients presenting with civilian trauma. Interventions: Spiral vein graft interposition and postoperative intermittent pneumatic calf compression. Main outcome measure: Limb salvage, vein patency and limb swelling. Results: Satisfactory limb salvage, femoral vein patency and absent limb swelling in both cases. Keywords: Femoral vein reconstruction; Pneumatic calf compression |
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| Correspondence and offprint requests to: A. Qureshi, Department of Vascular Surgery, Hull Royal Infirmary, Kingston Upon Hull, UK. | ||
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Send e-mail to p.coleridgesmith@ucl.ac.uk
Copyright © 2000 Philip Coleridge Smith
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