CONTENTS  •  Volume 13  Number 4 1998

Editorial

Original Articles

142 Preoperative Digital Photoplethysmography Predicts Improvement in Venous Function after Superficial Venous Surgery for Chronically Ulcerated Limbs
J.G. Sullivan, A. S. K. Ghauri, M. R. Whyman and K. R. Poskitt

148 Improving the Diagnosis of Chronic Leg Ulcers: a One-Stop Vascular Assessment Clinic in a Community Service
A.S. K. Ghauri. I.C. Currie, A. J. Grabs, M. R. Whyman, J. R. Farndon, and K. R. Poskitt

153 A Simple Technique to Reduce Blood Loss and Improve Cosmesis in Varicose Vein Surgery
A.Rehman, V. S. P. Rallapalle, H. Iqbal, R. P. Grimley and A. P. Jayatunga

157 Topographical Structural Variations of the Human Long Saphenous Vein and its Age-Related Remodelling as Revealed by Correlated Light and Scanning Electron Microscopy
A.Caggiati, G. Macchiarelli and G. Familiari

Short Communications

166 Left Renal Vein Anatomical Anomalies: Radiological and Surgical Implications
J. I. Martinez-Leon, C. Doménech-Pérez, J. Martinez-León, C. Martinez-Castillo and A. Martínez-Almagro

Case Report

Letter

Philip D. Coleridge Smith

This issue contains two papers by the same authors (Sullivan et al. [1], Ghauri et al. [2]) which address the problem of how best to evaluate patients with venous ulceration. In the first paper [1] a modern adaptation of an old technique, photoplethysmography (PPG), is used to assess if the outcome of superficial venous surgery can be predicted in a group of patients with venous ulceration. The authors show that the venous refilling time predicted by a thigh tourniquet used to occlude the long saphenous vein indicates reasonably reliably the likely effect of superficial venous surgery. in this study all patients treated by superficial venous surgery were thought to have venous disease confined to the superficial veins. In the majority of patients (80%), healing was obtained within 12 weeks, confirming that this was appropriate management in this group. The few patients who failed to heal their ulcers tended to have worse venous function, but some had venous refilling times in the range 15—30s, suggesting that some additional factor was the cause of failure to heal. Although this study clearly shows that photoplethysmography predicts the likely improvement in venous function, it also shows that this test will not necessarily show who will heal and who will not! The more challenging questions arise where patients with deep and superficial venous incompetence are included. A number of studies have shown that a substantial proportion of patients with leg ulceration have both superficial and deep vein incompetence. Some may benefit from superficial venous surgery and some may not. It has been found that patients with post-thrombotic deep vein damage generally derive little benefit from superficial venous surgery whether or not this includes the perforating veins. However, some patients appear to have non-thrombotic (primary) deep vein incompetence and this is a possible group where superficial venous surgery may improve the overall venous function and lead to ulcer healing. The question is which patients would be most suitable to treat in this way?

The second paper from the same authors [2] shows that about half of their patients presenting for management of venous ulceration had combined superficial and deep venous incompetence. The authors have not analyzed the deep vein incompetence according to probable aetiology from their duplex ultrasonography. A proportion of these patients might be helped by superficial venous surgery. One of the limitations of photoplethysmography in its earlier form was that the amplitude of the trace had no meaning since calibration was not possible. Digital PPG now allows these data to be assessed by a ‘pump efficiency’ parameter. Sullivan et al. have reported some of the data from this measurement, and it seems that the changes in this parameter parallel those from the refilling time measurement. However, these have not been analyzed further and so presumably offer no additional help in patient management.

Previous authors have used a number of other physiological tests for venous function, including ambulatory venous pressure measurements and air plethysmography. Several papers describe the use of venous function parameters derived from these tests in the management of patients with venous ulceration. However, it has been pointed out that the use of tourniquets does not necessarily indicate what the effect of surgery will be in individual patients. The graphs in the paper by Sullivan et al. show that although in a population of patients reasonable correlation between predicted and actual improvements in venous function can be obtained. On an individual patient basis reliable predictions are difficult to obtain. Consequently, although any of the above venous function tests will give a guide to what may be achieved by surgery, the actual improvement cannot be accurately determined. In some patients venous ulcers persisted despite the normalization of PPG refilling time after surgery. This suggests that some additional factor was the cause of the ulcer in these patients, not just the venous reflux. Whatever this was it had not been assessed by preoperative PPG measurements.

To me it seems that no test will reliably predict which ulcers will heal and which will not! Tests of venous physiology give an indication of what may be achieved by surgery and are helpful when considering marginal cases. Duplex ultrasonography provides anatomical information, useful in assessing which veins are at fault and in which patients post-thrombotic vein damage is present. This information is invaluable in individual patient management, as is indicated in the paper by Ghauri et al. They found that duplex ultrasonography is more useful than PPG for this purpose. It appears to be the investigation of choice in a ‘one stop clinic’. I think that no patient should be denied the possibility of healing their ulcer by undergoing superficial venous surgery on the basis of a physiological test. On the other hand, there is considerable evidence that superficial venous surgery, including perforating vein ligation, has little to offer patients with extensive post-thrombotic deep vein damage. As yet the ideal investigation to identify precisely which patient will benefit from superficial venous surgery is not available. The choice of treatment in each case must be selected on the basis of clinical criteria, duplex ultrasonography and tests of venous function, although I would not want to place firm rules on how the information from these investigations should be used.

References

1. Sullivan JO, Ghauri ASK, Whyman MR, Poskitt KR. Preoperative Digital Photoplethysmography Predicts Improvement in Venous Function after Superficial Venous Surgery for Chronically Ulcerated Limbs. Phiebology 1998;13: 142—7.

2. Ghauri ASK, Currie IC, Grabs AJ, Whyman MR. Farndon JR. Poskitt KR. Improving the Diagnosis of Chronic Leg Ulcers: A One-stop Vascular Assessment Clinic in a Community Service.  Phlebology 1998;13:14S—52.

Contents

A.Sobaszek¹, P. Frimat¹, A. Tiberguent², A. Domont², H. Chevalier³ and P. Catilina⁴
Service de Médecine du Travail Ct des Maladies Professionelles, ¹CHU de Lille, Lille and ⁴CHU de Clermont-Ferrand, Clermont-Ferrand, ²lnstitut de Mddecine et Sante au Travail, Paris, and ³SOFRES Medical, Montrouge, France

Findings: VI is highly prevalent: 76% of subjects and up to 84% in the surgical room and laundry population. Functional symptoms and the presence of varicosities (small varicose veins of the ankle and medial plantar arch) and large varicose veins are more frequent, with the highest prevalence among operating room staff (respectively, 68% and 41%). Seniority is the first and main factor to explain the severity of the disease, independently of age. The number of pregnancies is also an important factor for the severity of VI, while a family history is not. Occupational factors such as high temperature and load-carrying have a significant direct influence.

Keywords: Varicose veins; Venous insufficiency; Working conditions

Correspondence and offprint requests to: A. Sobaszek, Service de Médecine du Travail et des Maladies Professionelles, CHU de Lille, 2 avenue Oscar Lambret, F59037 Lille Cédex, France. 

Tel: 33-03-20.44.56.02; Fax: 33-03-20.44.55.91.

Contents

J. G. Sullivan, A. S. K. Ghauri, M. R. Whyman and K. R. Poskitt
Department of Vascular Surgery, Cheltenham General Hospital. Cheltenham, Gloucestershire, UK

Objective: To evaluate digital photoplethysmography (d-PPG) in predicting the influence of superficial surgery on venous function in chronically ulcerated limbs.

Keywords: Duplex; Leg ulcer; Photoplethysmography; Superficial venous surgery

Correspondence and offprint requests to: Mr K. R. Poskitt. Department of Surgery, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, UK. 

Tel: 01242-273 105; Fax: 01242-273 643.

Contents

A. S. K. Ghauri, I. C. Currie, A. J. Grabs, M. R. Whyman, J. R. Farndon, and K. R. Poskitt
Department of Surgery, Cheltenham General Hospital, Cheltenham, Gloucestershire, UK

Objective: To evaluate the influence of a specialized vascular-led community leg ulcer service on assessment and diagnosis of leg ulcers.

Design: Before-and-after study with prospective and retrospective data collection.

Setting: East Gloucestershire, England, UK.

Subjects: Patients treated for chronic leg ulcers before and within a specialized service incorporating a one-stop assessment including ankle-brachial pressure index (ABPI) and colour venous duplex.

Main outcome measures: The means of assessment and the identified aetiology of leg ulcers in community patients.

Results: Before clinics, only 40 (26%) limbs had a diagnosis recorded. After clinics, 83 (21%) limbs had arterial disease, including 64 (16%) with mixed arterial! venous disease. Venous duplex identified 279 (70%) limbs with venous disease of which 121 (43%) had superficial venous disease alone.

Conclusion: A one-stop assessment clinic with ABPI and colour venous duplex ultrasound within a specialized community service improves diagnosis of leg ulcers. This is essential before appropriate and safe management by specialist nurses in the community.

Keywords: Colour venous duplex: Community leg ulcer clinics; leg ulcer

Correspondence and offprint requests to: Mr K. R. Poskitt. Department of Surgery, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, UK. 

Tel: 01242-273 105; Fax: 01242-273 643.

Contents

A. Rehman, V. S. P. Rallapalle, R. Iqbal, R. P. Grimley and A. P. Jayatunga 
Vascular Surgical Unit, Dudley Group of Hospitals, Dudley, UK

Objective: To assess the effectiveness of preoperative compression hosiery in reducing blood loss during surgery for varicose veins and improving cosmetic results.

Setting: Vascular Surgical Unit, Dudley Group of Hospitals NHS Trust, West Midlands, UK.

Design: Randomized, single-blind, prospective, controlled trial.

Patients: Thirty-nine patients with varicose veins in 50 legs.

Intervention: Group A, the control group (n = 19), were given compression stockings on the first postoperative day after the bandages were removed. Group B, the study group (n = 20), used compression stocking 24 h before surgery as well as in the postoperative period. The surgical procedure was standardized.

Main outcome measures: Blood loss, weight of veins removed, operation time and cosmetic result after 6 weeks.

Results: In group B, patients were noted to have reduced blood loss, a shorter operation time and a greater weight of avulsed veins. Poor cosmetic results were recorded in group A.

Conclusions: Preoperative emptying of veins by using a compression stocking is useful in reducing blood loss and improving the cosmetic result after routine varicose vein surgery.

Keywords: Blood loss: Compression stocking; Cosmesis; Varicose veins

Tel: 01384-456111 ext. 2243: Fax: 01384-244 051.

Contents

Topographical Structural Variations of the Human Long Saphenous Vein and its Age-Related Remodelling as Revealed by Correlated Light and Scanning Electron Microscopy

A. Caggiati, G. Macchiarelli and G. Familiari
Department of Anatomy, Faculty of Medicine, University of Rome ‘La Sapienza’, Rome,Italy

Objective: To study topographical variations of the healthy human long saphenous vein structure and its age-related changes.

Methods: One hundred and forty-four specimens taken at different levels from 36 long saphenous veins were studied by correlated light microscopy and scanning electron microscopy.

Results: Continuous remodelling occurs in the wall of the long saphenous vein during the progress of life. In young subjects, the intima was narrow, circular muscular cells were present only in the media, and a rich elastic framework was evident in all the three tunicae. A progressive increase in collagen content and longitudinal musculature accompanied by a reduction in elastic tissue was observed in relation to ageing. Furthermore, at all ages. the saphenous vein wall thickened in its caudal portion due to a greater cellular proliferation and deposit of extracellular matrix.

Conclusions: The topographical variations in saphenous wall structure as well as its age-related remodelling likely represent the parietal reaction to the physiological hydrostatic load related to the vertical pasture.

Keywords: Ageing; Human; Saphenous vein; Structure; Vascular remodelling

Tel: 39-6-4462623; Fax: 39-6-4452349.

Contents

U. Baccaglini, E. Giraldi, G. Spreafico, P. Sorrentino, C. Castoro, S. Penzo, P. Pavei and M. Pignataro
Day Hospital, Istituto di Chirurgia Generale II, University of Padova, Italy

Objective:To test the Jobst ulcer care system (JUCS), a combination of two elastic stockings and a dressing, for the treatment of venous ulcers.

Keywords: Compression stocking; Venous ulcer; Wound dressing

Tel: 0039-49-8215671; Fax: 0039-49-8215672.

Contents

J. I. Martinez-Leon¹, C. Domënech-Pérez², J. Martinez-Leon². C. Martinez-Castillo³ and A. Martinez-Alniagro^3
1Unidad de Angiolugía y Cirugia Vascular. Hospital Universitario Puerta del Mar. Cadiz, and ²Departamento de Cirugia and ³Unidad de Anatomia Clinica. Departamento de Ciencias Morfológicas, Facultad de Medicina y Odontologia. Universidad de Valencia, Spain

Objective: To emphasize the incidence and clinical, diagnostic and surgical implications of left renal vein developmental anomalies.

Design: Retrospective analysis of case notes.

Setting: Clinical Anatomy Department and Surgery Department, Faculty of Medicine, University of Valencia. Spain.

Patients, participants: Standard radiological examinations (CT scan) performed on 745 patients; surgical findings at operation in 128 patients with aorto-iliac atherosclerotic disease, and 72 donor cadavers for transplantation.

Main outcome measures: Incidence of left renal vein anomalies (retro-aortic left renal vein and peri-aortic renal venous collar), based on radiological (CT scan) and surgical observations. Analysis of implications to surgical management.

Results: The radiological series disclosed a 2.68% incidence of left renal vein anomalies: 1.33% retro-aortic left renal vein, and 1.33% peri-aortic renal venous collar. The surgical series showed a 1.5% incidence of both anomalies.

Conclusions: The importance is stressed of these relatively uncommon but hazardous conditions, which should be familiar to anatomists, radiologists and surgeons.

Keywords: Periaortic renal vein; Retro-aortic — renal vein; Venous anomalies

Correspondence and offprint requests to: José Ignacio Martinez-León, Unidad de Angiologia y Cirugia Vascular (4^o Planta), Hospital Universitario Puerta del Mar, Avda Ana de Viya 21. 11009 Cadiz, Spain. 

Tel: (956) 242491

Contents

M. Jalaluddin¹, E. J. Parnell² and C. R. R. Corbett¹
Departments of ¹General Surgery and ²Orthopaedic Surgery, The Princess Royal Hospital. Haywards Heath, West Sussex, UK

Objective: To report a rare case of venous aneurysm.

Design: Case report.

Setting: Departments of General Surgery and Orthopaedic Surgery, The Princess Royal Hospital, Haywards Heath, a district general hospital.

Patient, intervention and results: A 63-year-old woman underwent revision of a right total hip replacement in 1994. using a cemented prosthesis. She continued to have pain in the region of the hip and a pulsatile swelling was noted in the right iliac fossa. A pseudo-aneurysm of the external iliac artery was suspected but investigations showed a venous aneurysm of the external iliac vein. Thus far, this aneurysm has been observed without complication. In 1996 the prosthesis was revised because of loosening of the femoral component and the pain resolved.

Conclusion: Vascular injury is a rare complication of total hip replacement and thermal arterial injury can occur. Iliac venous aneurysms are recognized but are extremely rare so we conclude that this lesion was caused by thermal injury.

Keywords: Aneurysm; Arthroplasty; Hip; Iliac; Replacement; Venous

Contents

Copyright © 2000 Philip Coleridge Smith