CONTENTS  •  Volume 14  Number 4 1999

Editorial

Original Articles

143   The Impact of Duplex Scanning for the Diagnosis of Deep Vein Thrombosis on Workload in a District General Hospital
S. Sudhindran, S. Rosser, W, J. Pilbrow, G. R. J. Sissons and L. M. de Cossart

146   The Relationship Between Ultrasonic Ambulatory Venous Pressure and Residual Volume Fraction in Primary Venous Insufficiency
P. Zamboni, 0. Quaglio, C. Cisno, F. Marchetti, L. Cisno and M. C. Marcellino

151   The Beneficial Augmentative Effect of Micronised Purified Flavonoid Fraction (MPFF) on the Healing of Leg Ulcers: An Open, Multicentre, Controlled, Randomised Study
W. Glinski, B. ChodynickaJ. Roszkiewicz, T. Bogdanowski, B. Lecewicz-Toruñ, A. Kaszuba, J. Bowszyc, A. Nowak, J. Wnorowski, F. W?sik, M. Glihska-Ferenz, M. Blaszczyk, P. Strzyga and R. Pachocki

158 Endostripping: A New Minimally Invasive Technique for Limited Stripping of the Greater Saphenous Vein
A. Shamiyeh. P. Schrenk, R. Rieger and W. Wayand

162   Lycra Support Tights: Are They Effective?
E. M. de Boer, R. W. Broekhuijsen, C. Nieboer and P. D. Bezemer

Case Report

Letters

169

Philip D. Coleridge Smith

Ultrasound imaging has become widely used in the management of patients with vascular disease of the lower limb, as it has in other medical specialities. In patients with venous disease the use of duplex ultrasonography has led to much better understanding of the pathophysiology of venous diseases as well as facilitating the management of patients with venous disease. Phlebography has dominated research and clinical in this field until recently. Curiously, although this technique was widely used and much of our understanding of venous disease is based on it, it is very hard to find studies in which the reliability or accuracy of phlebography is compared with any other method of investigation. Descending phlebography has been used extensively to study deep venous incompetence, however, whilst there are studies which show some correlation between clinical severity of venous disease and the extent of deep vein incompetence on descending phlebography, the reliability and repeatability of this method have not been studied in detail. Since descending phlebography to study valvular incompetence relies on the use of high density contrast media and not the flow of blood to test deep vein valves there must he some doubt about the validity of data obtained in this way. Duplex ultrasonography has the ability to assess blood flow in a non-invasive way. Comparisons between duplex ultrasonography and venography have been made in the assessment of deep vein incompetence. Ultrasound detects more incompetent deep vein segments than phlebography, especially at the popliteal level in patients with skin changes and leg ulceration. The experience of those who frequently use ultrasound to study blood flow in veins is that valvular incompetence may affect a segment of vein, either in the superficial or deep venous system of the lower limb. Varicose veins may be attributable to long saphenous vein incompetence in the presence of a competent saphenous femoral junction. Patients with a competent common and superficial femoral vein may have an incompetent popliteal vein leading to severe symptoms in the calf. This may explain why an injection of radiological contrast medium at the level of the femoral vein does not result in detect ion of distal venous incompetence in some patients.

The findings from duplex ultrasonography have led to significant changes in clinical practice. In the management of varicose veins it used to be common surgical practice to ligate the saphenous femoral junction and leave the long saphenous vein in place. The fate of the saphenous vein remained unknown until the advent of modern duplex ultrasonography. A number of authors demonstrated that this vein remained patent in many patients and was also incompetent in a substantial proportion, usually filling from residual tributaries rather then incompetent thigh perforating veins. A number of authors have observed that the residual incompetent long saphenous vein may lead to the development of recurrent sapheno-femoral incompetence as well as the development of further calf varices. Recently a clinical study has demonstrated that stripping the long saphenous vein for varicose veins has a better long term outcome than sapheno-femoral ligation alone, confirming the long-held prejudices of enthusiasts of duplex ultrasonography. Some authors in continental Europe have taken duplex findings to heart and have removed only those segments of vein proven to be affected by valvular incompetence. I think that this ignores the natural progress of disease from more distal to more proximal veins, originally described by Professor George Fegan nearly 50 years ago! I suspect than any residual segment of vein left behind in these circumstances may become incompetent leading to further varices.

The diagnosis of deep vein thrombosis is another field where ultrasonography has taken over. De Cossart et at. discuss this in their paper on the influence of ultrasonography on the use of phlebography in their hospital [1]. In fact, much has been written on this subject and there is no doubt that duplex ultrasonography has replaced phlebography in many centres for the investigation of suspected DVT. This has brought a number of problems with it. Certainly, ultrasonography is a far less invasive technique for the assessment of the deep veins but this has resulted in a lower threshold for ordering this test on patients. In some series, as few as 10% of patients had deep vein thrombosis confirmed by experienced vascular technologists from the large number of patients referred with only vague clinical signs suggesting calf vein thrombosis. De Cossart et al. addressed this problem by introducing the use of light reflex rheography as a screening test before duplex ultrasonography was undertaken. Some radiologists consider that calf vein thrombosis cannot be reliably detected by duplex ultrasonography and never examine the calf. This is a pity since calf vein thrombosis is often visible on ultrasound images, even it’ the sensitivity of’ this investigation is less in the calf than in the femoral and popliteal veins. Calf vein thrombosis may extend to the popliteal vein leading to more extensive deep vein damage and the risk of pulmonary embolism. In addition, diagnoses such as ruptured Baker’s cyst, calf haematoma or tumour in the calf muscles, all of which I have seen on more than one occasion, may be missed if the calf is not examined. Unless it is the routine practice of a technologist, radiologist or surgeon to examine the calf using ultrasound it is unlikely that he will recognise abnormalities when they are present in this region.

So ultrasonography is here to stay! It is unlikely that phlebography will retain its usefulness, except for patients requiring major venous reconstructions. Further advances in ultrasound imaging will provide still better image quality especially in the calf veins which can sometimes be difficult to assess. We shall hopefully discover more about the pathology of venous diseases with this technique but should not become obsessed in treating the ultrasound image rather than the patient!

References

1. Sudhindran S. Rosser S, Pilbrow Wi. Sissons GRJ, de Cossart LM. The impact of duplex scanning for the diagnosis of deep vein thrombosis on workload in a district general hospital. Phiebology  1999:14:14345.

Contents

C. J. Moffatt¹, D. A. Simon², P. J. Franks¹, M. Connolly¹, S. Fielden³, L. Groarke² and C. N. McCollum^2
1Centre for Research & Implementation of Clinical Practice, Thames Valley University. Wolfson Institute of Health Sciences, London; ²Department of Surgery, University Hospital of South Manchester, Manchester; and ³Riverside Community Healthcare Trust, Parsons Green Health Centre, London, UK

Objective: To compare a new four-layer bandage system (Profore) with the original 4LB in the closure of chronic leg ulceration.

Design: Prospective randomised stratified parallel-groups open trial.

Methods: Patients newly presenting to community leg ulcer services with chronic leg ulceration were screened for inclusion in this trial. Patients with arterial disease (ankle brachial pressure index <0.8) and causes of ulceration other than venous disease were excluded. In patients with bilateral ulceration, the limb with the larger area of ulceration was studied. The ulcer was dressed with a simple low-adherent dressing and all bandages were changed weekly unless required more frequently. Patients were randomised to receive either the original four-layer bandage or the newer system (Profore).

Results: In all 233 patients were randomised, of whom 232 attended at least one follow-up visit (115 original, 117 Profore). At 12 weeks complete healing of the ulcerated limb, analysed by ‘intention-to-treat’ was 60% using the original 4LB compared with 72% using Profore. The difference of 11.8% (95% confidence interval (CI) —0.3% to 23.9%) had largely disappeared after 24 weeks, with 73% healed using the original 4LB and 76% using Profore, a difference of 3.0% (95% CI - 8.2% to 14.2%). After 24 weeks of treatment the Kaplan-Meier estimate of complete healing was 82% using the original system and 84% using the Profore system. Overall, there was a higher healing rate for patients on Profore (hazard ratio = 1.18, 95% CI 0.87 to 1.59), but this did not achieve statistical significance (p = 0.28).

Conclusion: Ulcer healing using the newer Profore system is as good as with the original four-layer system.

Keywords: Chronic leg ulceration; Closure; Four-layer bandage; Randomised clinical trial

Correspondence and offprint requests to: Dr P. J, Franks, Centre for Research & Implementation of Clinical Practice, Thames Valley University, 32-38 Uxbridge Road, London W5, UK.

Tel: 44 (208) 280 5020. Fax: 44 (208) 280 5285.

Contents

S. Sudhindran, S. Rosser, W. J. Pilbrow, G. R. J. Sissons and L. M. de Cossart 
Countess of Chester Hospital. Chester, UK

Objective: To assess the impact of changing from ascending phlebography to colour flow duplex (CFD) scanning for the investigation of deep vein thrombosis (DVT) in a District General Hospital and to determine the role of light reflection rheology (LRR) as a preliminary screening tool for DVT.

Design: Retrospective audit.

Setting: Vascular Laboratory and Department of Radiology of the Countess of Chester Hospital, Chester, UK.

Patients and methods: Audit and review of the all venograms done during the years 1989 to 1991 was undertaken. All the LRR and CR) scans done from 1991 (year of introduction in this hospital) to 1996 were audited and analysed.

Outcome measures: Total number of various investigations done for suspected DVT in this hospital from 1989 to 1996 and their detailed analysis.

Results: Four hundred and ninety-four venograms were performed between 1989 and 1991, of which 44% confirmed DVT. The least number of venograms was performed in 1991 (n = 127), after the introduction of LRR. From 1991 through to 1996, the number of LRR scans increased from 90 to 697 and the CFD scans increased from 97 to 786.

Conclusion: The audit revealed a 6-fold increase in demand for the examination of limbs for suspected DVT after the introduction of non-invasive tests. LRR continues to be a useful screening tool, reducing the number of CFD scans by 23%.

Keywords: Ascending phlebography; Colour flow duplex scan; Deep vein thrombosis: Light reflection rheography

Contents

P. Zamboni, D. Quaglio, C. Cisno, F. Marchetti, L. Cisno and M. G. Marcellino 
Department of Surgery and Vascular Laboratory, University of Ferrara, Ferrara, Italy

Objective: To study the relationship between two non-invasive methods for determining ambulatory venous pressure (AVP) in primary chronic venous insufficiency of the lower limbs.

Design: Comparison between ultrasonic AVP (US-AVP) and residual volume fraction (RVF) determined by means of air plethysmography (APG).

Setting: Department of Surgery and Vascular Laboratory, University of Ferrara, Italy.

Patients: Twenty-one subjects affected by primary chronic venous insufficiency (CV I).

Main outcome measure: A comparison of the AVP values extrapolated from the change in ultrasonic diameter of the saphenous vein after exercise and from RVF values. Ultrasonographic extrapolation was also made by the means of the software Venometer and compared with manual assessment.

Results: Linear regression analysis demonstrated that US-A VP values were significantly correlated with RVF values (r = 0.86 and p<0.0001). Assessment by Venometer as compared with manual calculation showed a high degree of correlation (r = 0.98), p<0.000l).

Conclusions: The two methods for non-invasive assessment of AVP appear to be closely and significantly correlated. The Venometer allows reliable and rapid extrapolation of AVP values.

Keywords: Air plethysmography; Ambulatory venous pressure; Duplex scanning; Non-invasive vascular test; Residual volume fraction; Venous function

Correspondence and offprint requests to: Paolo Zamboni. MD. Department of Surgery, University of Ferrara, 1-44100 Ferrara, Italy.

Tel: +390 532 236524. Fax: +390 532 249358. E-mail: zmp@dns.unife.it

Contents

W. Glinski¹, B. Chodynicka², J. Roszkiewicz³, T. Bogdanowski⁴, B. Lecewicz-Torun⁵, A. Kaszuba⁶, J. Bowszyc⁷, A. Nowak⁸, J. Wnorowski⁹,  F. Wasik¹⁰, M. Gliñska-Ferenz¹. M. Blaszczyk¹, P. Strzyga¹¹ and R. Pachocki^11
1Department of Dermatology, Academy of Medicine, Warsaw; ²Department of Dermatology. Academy of Medicine, Bialystok;
³Department of Dermatology, Academy of Medicine, Gdarisk; ⁴Departrnent of Dermatology, Academy of Medicine, Katowice;
⁵Department of Dermatology, Academy of Medicine. Lublin; ⁶Department of Dermatology. Academy of Medicine, Lodz;
⁷Department of Dermatology, Academy of Medicine, Poznan; ⁸Department of Dermatology, Academy of Medicine. Szczecin;
⁹Capital Dermatology Hospital, Warsaw; ¹⁰Department of Dermatology, Academy of Medicine, Wroclaw; and ¹¹Medical and
Scientific Department of Servier Polska. Warsaw, Poland

Objective: To determine the increase in healing rate of venous ulcer in patients receiving a micronised purified flavonoid fraction (MPFF) as supplementation to standard local care.

Design: A randomised, open, controlled, multicentre study.

Setting: Departments of Dermatology and University Outpatients Clinics.

Patients: One hundred and forty patients with chronic venous insufficiency and venous ulcers.

Intervention: Patients received standard compressive therapy plus external treatment alone or 2 tablets of MPFF daily in addition to the above treatment for 24 weeks.

Main outcome measure: Healing of ulcers and their reduction in size after 24 weeks of treatment.

Results: The percentage of patients whose ulcers healed completely was found to be markedly higher in those receiving MPFF in addition to standard external and compressive treatment than in those treated with conventional therapy alone (46.5% vs 27.5%; p<0.05, OR = 2.3, 95% CI 1.1—4.6). Ulcers with diameters <3 cm were cured in 71% of patients in the MPFF group and in 50% of patients in the control group, whereas ulcers between 3 and 6 cm in diameter were cured in 60% and 32% of patients (p <0.05). respectively. The mean reduction in ulcer size was also found to be greater in patients treated with MPFF (80%) than in the control group (65%) (p <0.05). The cost-effectiveness ratio (cost per healed ulcer) in the MPFF group was €1026.2 compared with €1871.8 in the control group.

Conclusions: These results indicate that MPFF significantly improves the cure rate in patients with chronic venous insufficiency.

Keywords: Compression treatment; Drug treatment; Flavonoids; Venous ulceration

Contents

A. Shamiyeh, P. Schrenk, R. Rieger and W. Wayand
Second Surgical Department and Ludwig Boltzrnann Institute for Operative Laparoscopy, General Hospital of Linz, Linz, Austria

Objective: To describe a new technique for limited stripping (in the thigh) of the greater saphenous vein (GSV) to avoid painful postoperative haematomas.

Design: Pilot study.

Setting: General Hospital Linz, Second Surgical Department, Linz, Austria.

Patients: Sixteen patients undergoing primary varicose vein surgery for varices on the long saphenous vein. CEAP clinical stage: C2 (n = 12), C3 (n = 4).

Intervention: Removal of the GSV from the thigh by endoscopic dissection with electrocautery division of the main tributaries. Phlebectomy for varices in GSV tributaries.

Main outcome measures: Clinical assessment of the extent of haematomas and cosmetic appearance.

Results: Fifteen of 16 operations were completed as intended without any technical problem. In one case conversion to conventional stripping was required due to adhesion of the saphenous vein to a previous operation scar in the thigh. The median total operation time for one limb was 57 mm. A postoperative haematoma occurred in only one patient. There was no additional postoperative complication.

Conclusion: Endostripping is a new technique for stripping of the GSV and reduces postoperative haematoma. It can be performed in a reasonable operation time and is safe. The value of this technique should be assessed in clinical trials.

Keywords: Endoscopic surgery; Surgical treatment; Varicose veins; Vein stripping

Contents

E. M. de Boer¹. R. W. Broekhuijsen¹, C. Nieboer¹ and P. D. Bezemer^2 
1Department of Dermatology and Department of Clinical Epidemiology and Biostatistics. Free University Hospital, Amsterdam, The Netherlands

Objective: To investigate the effect of two Lycra support panty hose (8 and 12 mmHg) on the development of oedema of the lower legs and on feelings such as tiredness, heaviness and burning or pain in the legs.

Design: Prospective study.

Setting: Department of Dermatology, Free University Hospital, Amsterdam, The Netherlands.

Subjects: One hundred and eight healthy women, 20—60 years of age. who had no signs of chronic venous insufficiency on examination (including Doppler ultrasound) and who worked full-time.

Main outcome measures: Diurnal lower leg volume changes (DVC) recorded by opto-electronic volume measurements and questionnaires on subjective feelings while wearing a control panty hose in comparison with the support panty hose.

Results: The mean DVC with control panty hose was +2.7%. With both types of support panty hose the mean DVC was significantly decreased to 2.3% (p <0.001). At inclusion complaints were common (8 1%). Support panty hose A (8 mmHg) decreased feelings of heaviness and tiredness significantly. No relation between the reduction in DVC and a decrease in complaints was shown. Support panty hose B was often ill-fitting due to an inadequate size-table.

Conclusion: Both types of support panty hose reduced the normal diurnal volume increase significantly and equally. Further investigations are needed in order to find the minimum compression for (almost) complete prevention of oedema. The decrease in subjective unpleasant feelings, significant for tiredness and heaviness in the case of panty hose A, was unrelated to a reduction in DVC.

Keywords: Chronic venous insufficiency; Healthy volunteers; Oedema; Optical leg volume meter; Support panty hose

Correspondence and offprint requests to: Dr E. M. de Boer, Department of Dermatology. Free University Academic Hospital, De Boelelaan 1117, NL-1081 HV Amsterdam, The Netherlands. 

Tel:  +31 20 444 0145. Fax: +31 20 444 014S.

Contents

A. Huang and D. L. McWhinnie   
Department of Vascular Surgery, Milton Keynes Hospital. Eaglestone, Milton Keynes, UK

Design: Case report.

Setting: Department of Vascular Surgery, Milton Keynes Hospital, a district general hospital.

Patient, intervention and results: A 57-year-old woman underwent SEPS for a venous ulcer secondary to an incompetent perforating vein. Post-operatively she developed a new ulcer directly over the site of the divided perforator. The ulcer healed completely with conservative bandaging treatment after 4 months.

Conclusion: We describe a complication of SEPS not previously reported. The perforating artery might have been divided inadvertently instead of the perforating vein. It is important to positively identify the perforating vein during SEPS before its division, especially in the presence of mixed arteriovenous disease.

Keywords: Complication; Iatrogenic; Subfascial endoscopic perforator surgery; Ulcer

Tel:  +44 (0)589 320 024, +44 (0)20 7486 0885.  Fax:  +44 (0)20 7486 0883.  E-mail:  andyhuang@talk21.com

Contents

Copyright © 2000 Philip Coleridge Smith