CONTENTS  •  Volume 7  Number 1 1992

This issue marks a turning point for Phlebology. It is the first produced by publishers Springer-Verlag. who expect to reach those interested in venous diseases in many countries through their world-wide representation. it is also my first issue as editor where I have been set the task of building on the standards of excellence reached by my predecessors, David Negus and Sidney Rose. This journal owes much to these pioneers who have built the reputation and readership of Phlebology largely by their own efforts.

The publishers and editorial committee have decided to increase the size of this journal to the A4 format in order to promote its scientific importance, increase the space available for original articles and ensure that it is no longer overlooked at the back of the library shelf. Readers will notice changes in style that bring us more in keeping with modern scientific standards. Prominent among these is the change to structured abstracts, which will ensure a more complete description of original scientific contributions in reference databases. I would suggest that contributors of scientific articles consult the new ‘Instructions for Authors’ section at the front of this volume before committing text to wordprocessor. I hope that with the support of our new publishers, this journal will become more widely read and referenced in more medical literature databases. (Phlebology is already indexed in Excerpta Medica.)

Design: Prospective investigation of the use of calf volume changes during treadmill work using dynamic strain-gauge plethysmography.

Setting: University Hospital, Zurich, Switzerland.

Patients: Eighteen patients with suspected venous claudication who had occlusions or stenoses in the femoral or iliac veins shown on phlebography and/or Duplex scanning, compared to a group of 20 healthy volunteers.

Interventions: Venous occlusion strain-gauge plethysmography was carried out, followed by continuous volume recording while on a treadmill set at 100 and velocity of 7 km/hr for 3 minutes or until pain forced the subject to stop.

Main outcome measure: Calf volume changes during exercise.

Results: Significant differences were observed in calf volume changes during exercise in the group of patients with venous stenoses or occlusions and symptomatic venous claudication.

Conclusion: Dynamic plethysmography during treadmill exercise allows objective confirmation of venous claudication.

Design: Prospective study in twelve patients undergoing major surgical treatment, including hip surgery. who would be considered at high risk of developing subsequent deep vein thrombosis.

Setting: Departments of Angiology and Vascular Surgery. Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.

Patients: Twelve patients receiving surgical treatment.

Interventions: Bilateral contrast phlehography was performed in all patients, combined with an immunoscintigraphic test of an Indium-111 labelled monoclonal antibody to fibrin. Patients with deep vein thrombosis were treated with full anticoagulation using hepann.

Main outcome measures: The presence of thrombosis on phlebography and the presence of isotopic labelling of suspected deep vein thrombosis on immunoscintigraphic scanning.

Results: Phlebography demonstrated venous thrombosis at 23 sites in veins, of which 22 were also detected by immunoscintigraphic scanning.

Conclusions: Indium-111 labelled monoclonal antibodies to fibrin may provide an alternative method of investigation for suspected deep vein thrombosis as an alternative to other non-invasive diagnosis methodologies.

Design: Non-randomised, retrospective study of patients referred for investigation of venous disease. Patients investigated included a group of 20 who had previously undergone fasciotomy of the lower limb, and a group of healthy controls.

Setting: Patients referred to St Goran’s Hospital, Stockholm, Sweden.

Intervention: Venous photoplethysmography, foot volumetry, strain-gauge plethysmography, photoplethysmography, Dopplex/Duplex ultrasound, phlebography, intravenous pressure and intramuscular pressure readings in various sub-groups.

Main outcome measures: Determination of sites of venous reflux in the lower limb using Duplex/Doppler and phlebography, and correlation of the results obtained with other methods of investigation of lower limb venous function.

Results: Poor correlation was found between descending phlebography and Duplex scanning, although good correlation was found between the number of segments with reflux and clinical condition. PPG recovery time was very variable, depending on transducer position, numbers of dorsiflexions performed, and reflux in superficial veins.

Design: Retrospective study in a series of patients treated surgically by the author.

Setting: Department of Surgery. Nepean Hospital, Sydney. Australia.

Patients: Patients presenting with clinical signs and symptoms of varicose veins attributable to sapheno-femoral incompetence.

Interventions: Patients underwent flush sapheno-femoral ligation with stripping of the long saphenous vein using a downward stripping of the long saphenous vein between the groin and knee.

Main outcome measures: Cosmetic appearance of the limb and presence or absence of neurological disturbance suggestive of injury to the saphenous nerve.

Results: Satisfactory healing of all wounds was found. Good aesthetic results and no neurological complication was encountered.

Conclusion: Groin to knee downward stripping of the long saphenous vein provides a safe and effective method for managing varices of the long saphenous vein.

Design: Prospective, closed, non-randomised study of 126 patients with a previous history of venous ulceration for five years.

Setting: The Varicose Vein Clinic of Sir Patrick Dun’s and Adelaide Hospitals.

Patients: 126 patients attending the Varicose Vein Clinic who had undergone successful healing of vcnous ulcers by injection compression sclerotherapy.

Intervention: All patients underwent clinical examination and venous pressure measurement, and were then fitted with graduated compression stockings. Those patients dropping out of the study (21) were used as a comparison group.

Main outcome measure: The recurrence rate of venous ulcers.

Results: At the end of the 5 year study period patients were divided into 3 groups — those who had ulcer recurrence (33), those who were free of ulcers (72), and those (21) who had dropped out of the study, the last group showing a higher recurrence rate than those who had worn stockings.

Design: A prospective study of saphenous veins obtained at post-mortem examination and jugular vein obtained at time of surgery.

Setting: Health Service district general hospital.

Patients: Patients with no evidence of venous disease being treated in the hospital for unrelated conditions, or examined at autopsy in the Department of Pathology.

Interventions: Sections of saphenous vein from the lower limb and jugular vein were examined using conventional histology, immunohistochemical staining and electron microscopy.

Main outcome measures: Microscopic and electron microscopic appearances of histological sections of venous valves.

Results: The valve agger contains an increased amount of fibrous tissue compared with the vein wall and saphenous and jugular veins. However, in saphenous veins the muscle layer of the wall could be traced across the base of the agger, but this was deficient in jugular valves. Electron microscopic examination showed that most of the valve cusp was composed of collagen fibrils, aggregated in irregularly arranged bundles. Elastic fibre material was present in the subendothelial zones. Nerve and muscle fibres were not present in the cusp.

Conclusions: Valve cusps in both high and low pressure systems are similar, and the authors suggest that cusp/ agger/vein wall complex is important for valve function.

Design: Prospective study in thirteen patients.

Setting: Health Service teaching hospital.

Patients: Thirteen patients with venous ulceration for 2 years.

Interventions: Patients were admitted to hospital for bed-rest and lower limb elevation for a period of 24 hours.

Main outcome measures: Limb volume was measured by water displacement and impedance plethysmography.

Results: During limb elevation there was a mean reduction limb volume of 524 mls (95% CI 377—671 mls) after 24 hours of bedrest. This corresponded with a reduction in impedance measured by the impedance plethysmograph of 19.0 ohms (95% CI 24.3 to 15.6 ohms).

Conclusion: Measurement of the lower limb volume by water displacement and by impedance plethysmography are likely to be useful methods in the investigation of patients with chronic venous insufficiency.

Design: Prospective study in patients receiving in patient treatment for venous ulceration.

Setting: Health Service teaching hospital.

Patients: Thirteen patients with venous ulceration of the lower limb for more than two years were investigated.

Interventions: Patients were admitted to hospital and treated by bedrest with elevation of the lower limbs by 100 above the horizontal.

Main outcome measures: Laser Doppler fluximetry and transcutaneous oximetry of the skin surrounding the venous ulcers was undertaken.

Results: The laser Doppler fluximetry in the peri-ulcerous region increased by 10.8 A.U.(95% CI 17 to 4.54). However, the transcutaneous oxygen measurements did not change during the period of treatment.

Conclusions: Admission to hospital with elevation of the limb for patients with venous ulceration results in micro-circulatory changes which are probably attributable to reduction in lower limb oedema.

Design: Series of three case reports.

Setting: Grondin Clinic. Calgary, Alberta, Canada.

Patients: Three patients with symptoms suggestive of deep vein thrombosis of the calf.

Interventions: Duplex ultrasound imaging in all patients combined with phlebography of the lower limb in one patient.

Main outcome measure: Presence of deep vein thrombosis or soft tissue abnormalities of the lower limb on ultrasound imaging or venography.

Results: A Baker cyst was found in one patient, an intramuscular haematoma in a further patient, both detected by ultrasound imaging, hut not by venography. In the third patient a venogram failed to demonstrate deep vein thrombosis in the calf, but this was detected on ultrasound imaging.

Conclusions: Ultrasound imaging is a valuable tool in reaching a diagnosis in patients presenting with symptoms suggesting deep vein thrombosis in the calf.