CONTENTS  •  Volume 7  Number 2 1992

It is with great pleasure that I have the privilege to publish the deliberations of world experts in the field of venous disease in the Consensus Paper on Venous Leg Ulcers. This was achieved after two ‘Alexander House’ meetings, in which the participants felt able to make recommendations to clinicians throughout the world in the management of venous disease. The final document owes much to the article editors, David Beatty and Hugh Boardman, who ensured the accuracy and appropriateness of references, as well as supplying the final style of the document without amending the meaning of the original statements. I am sure that you will agree that the final result is a precise, systematic statement of the present understanding and clinical science of phlebology as it should be practised.

In the last issue I reported on a European consensus on the prevention of deep vein thrombosis [1]. Valuable statements were made at the end of this meeting, which I summarized in brief for readers of Phlebology. Again, enormous efforts were made by the participants to ensure the accuracy and usefulness of the final document. But do such documents influence medical opinion and clinical management or are they neglected and their findings disregarded despite their excellence and authority?

In the United States, where consensus conferences organised by the National Institutes of Health (NIH) become part of national recommendations for management of health care, considerable importance is associated with consensus statements. Clinicians, administrators, economists and lawyers examine such statements in detail to determine whether there are medical, organisational, financial or legal reasons for modifying their practice. In most other countries administration of health care resources is not so democratic. Government departments responsible for administering health care resources appoint committees to advise on clinical and technical problems which may result in decisions being made without full reference to the experience that might be embodied in a team such as the ‘Alexander House’ group. In the United Kingdom, the organisation of a conference to advise the Department of Health on venous ulceration [2] has resulted in relatively small changes in the management of patients with venous disease, many of these attributable to the persuasive energy of the contributors to the conference, rather than at the instigation of the Department of Health itself! Clearly it would be highly desirable for the results of great deliberation and debate to become part of national health care policy, and yet this might remove some of the autonomy of individual clinicians if the statements of intent from a conference were to become embodied in edicts from the government of a country. In the United States, NIH Consensus Development Conferences have, to some extent, become regarded in this way since even if the administration did not insist on implementation of the conclusions, medico-legal practice obliged the ever-defensive clinician to comply. I hope that the Alexander House document becomes widely distributed, debated and regarded as a reference in the management of venous disease. It highlights both the extent of expertise in the management of these diseases as well as some of the large gaps in our understanding of the mechanisms at work in venous pathology.

1. Coleridge Smith PD. European workshop on the prevention of thromboembolism. Phlebology 1992;7:45~-6.

Design: The first trial involved patients who had undergone bilateral operations for varicose veins. Adhesive acrylate bandage was applied to the experimental limb and non-adhesive crepe to the control limb. The second trial involved patients with venous ulcers randomly allocated to two groups. The experimental group used the one layer acrylic adhesive bandage whilst the control was treated by the three layer bandage technique (zinc oxide paste bandage followed by a non-adhesive compression bandage and tubular overlay).

Setting: Hospital patients in the first trial and clinic patients in the second.

Patients, participants: First trial, ii patients with bilateral varicose veins of which 10 completed. Second trial, 15 patients in the experimental group and 12 patients in the control group all of which completed.

Results: Non-adhesive bandaging lost effective compression after 24 hours. Acrylic adhesive bandage maintained effective compression after 1 week. The rate of venous ulcer healing was similar between the one layer adhesive bandage group and three layer group. One layer adhesive bandaging took only one quarter of the time to apply (p<0.0l%).

Conclusions: Adhesive bandaging produced more effective sustained compression than non-adhesive crepe. Adhesive bandaging was as effective as the currently used three layer bandaging technique in healing venous ulcers and was quicker to apply.

Setting: Department of Vascular Radiology, St. Thomas’ Hospital, London, England.

Patients: Seventy patients with suspected deep vein thrombosis or pulmonary embolism were examined.

Interventions: Bilateral ascending contrast phlebography was performed in all patients.

Main Outcome Measures: The sites of any thrombus in the stem or muscle veins of the calf below the popliteal vein were recorded.

Results: One hundred legs contained thrombus. In fifty-three legs thrombus was present solely in the calf veins below the popliteal vein. Isolated thrombus in either one or more of the three paired stem veins or the muscle veins was present in twenty-two calves.

Conclusions: Because of the difficulty in visualising some calf veins by duplex ultrasound it is suggested that a detailed knowledge of the distribution of thrombus may assist ultrasonographers.

Design: Prospective study of 1,300 patients treated by stripping of the long saphenous vein by the invagination technique.

Setting: Three quarters of the patients were treated at a private clinic and one quarter in a university hospital in Brussels, Belgium. Patients underwent stripping of the long saphenous vein under local or regional anaesthesia.

Main outcome measures: The occurrence of peroperative haemorrhage, postoperative haematoma in the track of the long saphenous vein, when assessed by clinical examination and dysthaesia in the distribution of the saphenous nerve assessed by neurological examination.

Results: In a total of 1,300 patients operated on using the author’s technique there were only 6 haematomas in the track of the long saphenous vein and no serious peroperative haemorrhage was encountered. In 4 patients disturbances in the sensation in the area supplied by the saphenous nerve were detected.

Conclusion: Stripping the long saphenous vein by invagination provides a safe alternative to conventional methods which may cause excessive damage to structures around the vein.

Objective: To determine the current usage of prophylactic regimes to prevent deep vein thrombosis in surgical departments in Italy.

Design: Survey by questionnaire sent to 500 surgical departments.

Participants: Surgical departments performing more than 500 surgical operations, selected randomly by the process of quota sampling.

Main outcome measures: Assessment of the methods of prophylaxis reasons for use of prophylaxis and assessment of outcome of prophylactic measures.

Results: There were 326 completed questionnaires returned indicating that prophylaxis was used routinely in 58% of the centres, 29% of centres used more than 1 method of prophylaxis with subcutaneous heparin and elastic compression being the most commonly used modalities.

Conclusion: Insufficient use of prophylactic measures to prevent deep vein thrombosis in Italy still leads to an excessive number of postoperative venous thromboses.

Design: Prospective study using duplex scanning and photoplethysmography (PPG) as objective criteria of venous function.

Setting: The Middlesex Hospital Vascular Laboratory, a teaching hospital centre of referral for the investigation of venous disease.

Patients: Thirty patients with clinical unilateral primary varicose veins.

Results: All clinically abnormal limbs had abnormalities on investigation. However, four of 30 patients (l3~) also had abnormal duplex findings on the contralateral clinically normal limb, and six (20%) had abnormal PPG refilling times. A total of 26% clinically normal limbs could be demonstrated to have some abnormality of venous function using these two tests.

Conclusions: We have shown that the contralateral, clinically normal limb cannot be assumed to be normal without full formal venous assessment.

Design: Thirty-five long saphenous veins were examined. Compliance measurements have been calculated using: Method A in which an AV Impulse machine (Novamedix, UK) is used to generate a pulse wave in the long saphenous vein and the measurement of transit times are performed. Method B involves duplex ultrasound and venous occlusion of the long saphenous vein. Occlusive pressure measurements are used in both methods.

Results: The mean vein compliance ratio measured in 35 long saphenous veins with the different methods was 0.23 (0.18-0.28) and 0.26 (0.22-0.30) using method A and B respectively. (Mean and (95% confidence interval)). The results show that a good correlation r 0.91 and this was confirmed using methods of agreement.

Conclusion: Both techniques give comparable results, however, the method involving Duplex is easier to perform. The research and clinical implications of these techniques remain to be assessed.

Setting: University Hospital. Utrecht, The Netherlands.

Patients: One 62-year-old patient presenting with a 3 month history of leg ulcer.

Interventions: Diagnostic biopsy followed by radiotherapy and chemotherapy.

Results: Histological examination of the biopsy demonstrated a B-cell lymphoma which showed no recurrence during an 8-year follow up-period after treatment.

Conclusion: Primary cutaneous lymphoma is a rare cause of malignancy mimicking venous leg ulceration.