CONTENTS  •  Volume 12  Number 4 1997

Editorial

Original Articles

127   Edinburgh Vein Study: Methods and Response in a Survey of Venous Disease in the General Population
C. J. Evans, F. C. R. Fowkes. C. V. Ruckley, P. L. Allan, M. N. Carson, E. M. G. Kerracher and A..J. Lee

136   Angioscopic External Valvuloplasty in the Treatment of Varicose Veins
H. Satokawa, S. Hoshino, T. Igari, S. Takase and T. Ogawa

142   Graduated Compression Treatment in Patients with Chronic Venous Insufficiency:  A Study Comparing Low and Medium Grade Compression Stockings
C. Jungbeck, 1. Thulin, C. Darenheim and L. Norgren

146   Venous Thrombectomy in Pregnancy: A Follow-up Study
L. Eriksen, J. Pachler, J. Krogh Christoffersen, N. Baekgaard, M. Mantoni, J. 0. Lund, C. Lenstrup and B. Jacobsen

Meeting Report

Abstracts

Philip D. Coleridge Smith

In this issue Evans CJ al. report part of their study of the epidemiology of venous disease which has been conducted in Edinburgh. This represents a systematic attempt to better define the extent of venous disease, including varicose veins as well as ulceration. As vet. the full data from this study is not available, although I hope to be able to include more of the data in future issues of Phlebology. I have often observed how incomplete our understanding is in a number of subjects in venous disease. This appears to be another area in which full data has yet to be collected. Previous epidemiological studies have considered the prevalence, but not the annual incidence of venous disease. Knowledge of the latter is essential for adequate provision of healthcare. A common problem is recurrence following healing of venous ulceration, again well known, but without a simple solution. Current high-compression bandaging regimes, such as the 4-layer technique developed at Charing Cross Hospital in London, can achieve the healing of 60%—70% of ulcers within 12 weeks. However. follow-up studies in patients whose ulcers were healed by the 4-layer regime show that the annual recurrence rate is about 25%. Very similar rates of recurrence have been reported in many studies where systematic recording of the outcome of compression bandaging has been investigated. It seems doubtful whether any method of achieving ulcer healing results in a reduced recurrence rate, with one or two possible exceptions. The development of tissue growth factors and their use in leg ulcer healing following the original work of Knighton in 1988, offered the possibility of modifying the healing process. No convincing evidence of the superiority of management techniques in which tissue growth factors are applied topically to leg ulcers, has so far been reported. This treatment does not seem to achieve superior rates of venous ulcer healing or prevention of recurrence. A number of technical problems remain and research in this area continues. I view the failure of improved wound healing treatments to prevent re-ulceration as evidence that unless the factors which gave rise to the ulcer in the first place arc removed, then re-ulceration is likely. The results of surgery in patients with leg ulcers attributable to superficial venous incompetence alone suggest that an annual recurrence rate of 2%—3% is seen when the cause of ulceration (varicose veins) is removed. This is clearly a highly selected group of patients but recent evidence suggests that it may account for up to half the patients who present with venous ulceration. The proponents of sub-fascial endoscopic perforator surgery (SEPS) also believe that they may influence the eventual outcome, in a way which was not achieved by those who used open perforator ligation techniques. However, only clinical series of SEPS have been reported so far and randomised trials have yet to be concluded.

The resources used to achieve leg ulcer healing are considerable and represent a large investment in patient care. It is enormously wasteful that so many ulcers recur. The number of patients at risk of ulceration is about five times that of patients with open ulcers. but the costs of some form of preventive treatment in those most at risk may outweigh the much higher expenses of treating an open ulcer. I believe that this group deserves more attention and the development of regimes of management that are as effective in preventing re-ulceration as the 4.layer bandaging is in healing ulcers. It is clear that use of compression stockings prevent re-ulceration and it has been suggested that patient support groups may be helpful in ensuring that patients comply with the need to wear their stockings —forever! However, more sophisticated solutions may also be developed. I envisage that a patient might use a topical application on the ankle skin or a drug taken orally as well as wearing a compression stocking. The most attractive option would be for the use of a topical application, since this would avoid many potential problems with systemic side effects of a powerful drug. The difficulties in providing the efficacy of any new regime are considerable. In a closely observed cohort of patients the annual recurrence rate would probably fall, reducing the number of events’ (recurrent ulcers) available for analysis. In any case. a study would involve between 500 and l000 patients with healed ulcers. The logistics of organising such a study, even assuming a suitable treatment could be found, would he formidable. It would be preferable to prove the efficacy of the new treatment in leg ulcers healing studies before embarking on an ulcer prevention study. This makes the assumption that an ulcer healing drug might also act as an ulcer preventing drug. I believe that this is a reasonable assumption to make. In any event, it seems unlikely that it will be possible to dispense with compression treatments in patients with chronic venous disease for the foreseeable future.

Contents

M. Saharay¹, D. A. Shields¹. J. B. Porter², J. H. Scurr¹ and P. D. Coleridge Smith¹
Departments of ¹Surgery and ²Haematology, University College London Medical School, London, UK

Objective: To investigate leucocyte activation in normal volunteers subjected to short-term venous hypertension by measuring the cell surface expression of the integrin CD11b and the selectin CD62L on neutrophils and monocytes before and after short-term venous hypertension. Plasma levels of L-selectin, which is shed by leucocytes upon activation, were also measured.

Design: Prospective study, measuring white cell count, neutrophil and monocyte surface CD11b and L-selectin expression in whole blood using a fluorescent-labelled monoclonal antibody in a flow cytometer. and plasma L-selectin by a commercially available ELISA.

Setting: The Middlesex Hospital Vascular Laboratory. a referral centre for the investigation of venous diseases.

Subjects: Twenty-five normal volunteers without any history or clinical finding of venous disease.

Results: There was a significant fall in the white cell : red cell ratio (p = 0.03, Wilcoxon) in response to venous hypertension. followed by a significant increase (p <0.001. Wilcoxon) when the venous hypertension was reversed. Neutrophil and monocyte CD1 lb levels fell significantly (p <0.001 and p <0.001, Wilcoxon) in response to venous hypertension. On reversing the venous hypertension a significant increase of CD11b expression was noted in both neutrophils and monocytes ~p<0.00l and p<0.01. Wilcoxon). Surface L-selectin expression, however, showed a significant sustained fall in both neutrophils and monocytes (neutrophils, p = 0.05 and p = 0.02; monocytes, p = 0.04 and p = n.s.. Wilcoxon) throughout the experiment. There was a significant rise in soluble L-selectin in the plasma following venous hypertension (p<0.001, Wilcoxon).

Conclusion: This study demonstrates both neutrophil and monocyte activation in the microcirculation of normal volunteers in response to short-term venous hypertension.

Keywords: CD11b; L-selectin; Leucocyte adhesion; Venous disease; Venous hypertension: Venous ulceration - aetiology

Correspondence and offprint requests to: Mr M. Saharay, FRCS. Research Fellow, UCLMS, The Vascular Laboratory, Jules Thorne Building, The Middlesex Hospital, Mortimer Street, London WIN 8AA. UK.

Contents

C. J. Evans¹. F. G. R. Fowkes¹, C. V. Ruckley². P. L. Allan³. M. N. Carson¹, E. M. G. Kerracher¹ and A. J. Lee^1
1Wolfson Unit for Prevention of Peripheral Vascular Diseases, Department of Public Health Sciences, University of Edinburgh; ²Department of Surgery and ³Departmcnt of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK 

Objective: To describe the methods required to conduct a large epidemiological study of venous disease in the general population, and the resulting response.

Design: Cross-sectional study.

Setting: University of Edinburgh.

Participants: Men and women aged 18—64 years, randomly selected from general practice registers.

Methods: Subjects were invited for the following procedures: questionnaire, height and weight measurement, classification of varices and chronic venous insufficiency, duplex measurement of duration of venous reflux and venous blood sampling. A questionnaire survey of non-responders was carried out.

Results of response: A total of 1566 subjects attended, a final response rate of 53.8%. The response. rate increased with age. The distribution of ethnic origin and social class of attenders was similar to that of the general Edinburgh population. Study participants were generally older, from more affluent areas and more often female than non-responders (p≤0.00l).

Conclusions: Large epidemiological studies of venous disease in the community are feasible but the level of response illustrates the importance of obtaining information on the disease status of non-responders.

Keywords: Duplex scanning; Epidemiology; Varicose veins; Venous incompetence

Correspondence and offprint requests to: Professor F. G. R. Fowkes, Wolfson Unit for Prevention of Peripheral Vascular Diseases, Department of Public Health Sciences, University of Edinburgh, Teviot Place. Edinburgh EH8 9AG, UK.

Contents

H. Satokawa, S. Hoshino. T. Igari, S. Takase and T. Ogawa
Department of Cardiovascular Surgery. Fukushima Medical College, Fukushima, Japan

Objective: To report on the surgical treatment of varicose veins by angioscopic valvuloplasty to preserve the long saphenous vein (LSV) and the efficacy of this method compared with conventional stripping and high ligation.

Methods: A total of 306 limbs in 187 patients with reflux at the sapheno-femoral junction to below knee level were operated on using intraoperative angioscopy to diagnose valve insufficiency. Angioscopic external valvuloplasty was attempted for the subterminal valves in the LSV by three techniques: total plication of the dilated annulus by running polypropylene sutures (technique 1). plication by autogenous femorofascial sleeve or Dacron-reinforced silicone (technique 2), and plication of the commissure with shortening of the cusps from outside the vein wall (technique 3). Partial stripping or segmental ligation was performed for varicose veins below knee level and the incompetent perforating veins were treated simultaneously by suprafascial ligation.

Results: The subterminal valves were classified as follows: valves with elongated and atrophic cusps — type I. 136 (44%); valves with expanded and depressed commissures with cusp changes — type H, 108 (35%); valves that had cusps with other deformities — type III 38 (13%); and absence of valves between the sapheno-femoral junction and mid-thigh level, 24 limbs (8%). Valvuloplasty of’ the LSV was successfully performed in 62 limbs (20%). There were two cases with occlusion of the LSV (3%) and four with recurrence of varicose veins (6%) at 2-89 (mean 55, SD 21) months follow-up.

Conclusions: Angioscopic external valvuloplasty is effective in the treatment of varicose veins to preserve the LSV. Further data are needed for complete evaluation of this procedure.

Keywords: Angioscopy; Long saphenous vein; Saphenous vein stripping; Valvuloplasty

Contents

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

Objective. Patients with chronic venous insufficiency (CVI) benefit subjectively from treatment with graduated compression stockings. Usually, class II compression is used in patients with CVI grade IL The present study investigates possible differences between graduated compression of classes I and II.

Design. Randomized study.

Setting. Department of Vascular Surgery and Vascular Laboratory, University Hospital. Lund.

Patients and Methods. Thirty-one patients, nine male and 22 female (59 legs), all with grade II CVI. Foot volumetry and a visual analogue scale (VAS) were used to assess symptoms. Patients were randomized to either class I or class II graduated compression, and the examinations were repeated after 8 weeks of treatment.

Results. The VAS assessment showed that all patients benefited to the same extent and there were no differences between the two compression classes. An increase of the expelled volume with compression was recorded, to a significant degree with class I compression. Reflux values were not significantly influenced by either grade of compression.

Conclusion. Class I graduated compression did not show any difference in subjective effect or objective parameters compared with Class II. Class I compression can be recommended instead of class H compression. especially in patients who find that the higher pressure on the leg causes discomfort.

Keywords: Chronic venous disease; Graduated compression stockings: Varicose veins

Correspondence and offprint requests to: Professor Lars Norgren, Department of Surgery. Lund University, S-221 85 Lung, Sweden.

Contents

Venous Thrombectomy in Pregnancy: A Follow-up Study 

L. Eriksen¹ , J. Pachier² J. Krogh Christoffersen^2, N. Baekgaard² , M. Mantoni³. J. 0. Lund⁴, C. Lenstrup² and B. Jacobsen⁵
Departments of ¹Obstetrics and Gynaecology, ²Vascular Surgery, ³Radiology and Ultrasonography, and ⁴Clinical Physiology and Nuclear Medicine, and ⁵Cuagulation Laboratory. Gentofte Hospital, University of Copenhagen, Denmark 

Objective: To evaluate women who have been treated by venous thrombectomy in pregnancy because of ilio-femoral venous thrombosis, reporting the outcome of their pregnancy and frequency of objectively measured venous insufficiency.

Design: A retrospective study. The patients were assessed by questionnaire, clinical examination, tests of venous function and ultrasonography.

Setting: Department of Vascular Surgery, Gentofte Hospital, University of Copenhagen.

Patients: Nineteen women treated previously by venous thrombectomy during pregnancy, with a subsequent pregnancy.

Results: None of the women had complications during subsequent pregnancies or deliveries, 47% had an occluded iliac segment and 53% had dilated or varicose veins. None had ulcers or skin changes. None of the women showed signs of re-thrombosis.

Conclusion: Women who have been treated for deep venous thrombosis in pregnancy by thrombectomy and arteriovenous fistula followed by anticoagulant therapy may undergo further pregnancies with a very low risk of obstetric complications and a low risk of developing re-thrombosis or chronic venous insufficiency.

Keywords: Pregnancy; Venous insufficiency; Venous thrombectomy

Contents

Copyright © 2000 Philip Coleridge Smith