CONTENTS  •  Volume 7  Number 3 1992

It is with great sadness that we report the death of two members of our International Editorial Advisory Board. Both Dr Dale, a vascular surgeon from Tennessee, and Dr Michael Lea Thomas, a radiologist from St Thomas’ Hospital, London, were part of the original Board at the instigation of this Journal. The success that Phlebology presently enjoys is at least in part the result of the efforts of these devoted experts.

Dr Dale’s work in the venous field involved the development of autogenous vein grafts to replace occluded veins. He performed and reported a successful series of crossover grafts for iliac vein occlusion. He was President of the Society of Vascular Surgery (of the USA) in 1974 and President of the North American Chapter of the International Society for Cardiovascular Surgery in 1980.

Michael Lea Thomas made outstanding contributions to the practice of radiology, particularly in connection with the elucidation of venous diseases. These are detailed in an obituary by David Negus (p. 134) in this issue. The work of Dr Lea Thomas has clearly led to many major discoveries in both research and the clinical practice of phlebology.

Perhaps this is the end of an era. At present there is an increasing number of methods for investigating the peripheral venous circulation. CT scanning has been available for several years, but offers only structural information, whereas the newer technique of magnetic resonance imaging offers the possibility of obtaining more information about the metabolism of the tissues, as well as blood flow. However, in more and more publications phlebography is being left behind, with a new preference for ultrasound imaging. Development of the generation of colour-flow ultrasound imaging systems offers the possibility of obtaining information as good as that from phlebography, without the need for ionizing radiation or intravenous injections. In the diagnosis of deep vein thrombosis it seems that, with a skilled operator, ultrasound imaging is as reliable as phlebography.

Despite this enthusiasm for a new technique, relatively few papers comparing phlebography and ultrasound imaging have been published. Although ultrasound imaging is widely used in the diagnosis of venous disease, conclusions about the value of quantitative functional data obtained from these tests should probably be regarded with some caution at present. Nevertheless, ultrasound imaging looks set to take over from virtually all other methods of venous imaging, bringing us into the age of the ‘colour duplex ultrasound phlebologist’!

It will be necessary to ensure that adequate training of such experts is undertaken since the reliability of findings from ultrasound examinations are highly operator-dependent. We must not forget that the same is true of venography. Without experts such as Michael Lea Thomas, the potential for new technology to reveal more useful information about pathological processes may not he exploited to its fullest extent.

Objective: To study changes in indicators of fibrinolytic activity and white cell trapping in response to raised venous pressure in the upper limbs of patients with chronic venous insufficiency.

Design: Comparison of disease group versus control group study.

Setting: Departments of Dermatology and Medicine, University of Freiburg.

Patient: Thirty patients with chronic venous insufficiency and thirty control subjects of similar age with unrelated conditions.

Interventions: The venous pressure was raised in one upper limb by application of a sphygmomanometer cuff around the upper arm for a period of 10 minutes.

Main outcome measures: Red cell count, white cell count, plasminogen activator inhibitor, tissue plasminogen activator were measured in blood drawn from the arm subjected to raised venous pressure.

Results: No significant changes were observed in the parameters of fibrinolytic activity. After 10 minutes of venous hypertension the white cell trapping in the disease group was 17.7% (interquartile range, 10.7—22), compared with 12.8% (interquartile range 4.9—16.1%) in the control group.

Conclusion: The differences in white cell trapping parameters between healthy control subjects and patients with chronic venous insufficiency is probably attributable to systemic activation of white cells associated with their venous disease.

Objective: Determination of the ratio of collagen and elastin to protein content of varicose/non-varicose veins from calf and determination of collagen, elastin and smooth muscle density of varicose/non-varicose vein walls.

Design: Prospective study; control vein samples obtained from amputees for ischaemic vascular disease and varicose vein samples obtained from an equivalent position following surgical stripping.

Setting: Departments of Human Morphology and Vascular Surgery, Queen’s Medical Centre, University of Nottingham, UK.

Patients: Seven patients with no evidence of venous disease treated by amputation of the lower limb for vascular disease and 12 patients treated for varicose veins by ligation and stripping of the long saphenous vein.

Interventions: Vein sections were examined biochemically and histologically using stereological techniques.

Main outcome measures: Biochemical quanitfication of collagen, elastin and protein and stereological analysis of collagen, elastin and smooth muscle density of varicose and non-varicose veins.

Results: There was no difference between the collagen! protein or elastin/protein ratio in varicose and normal veins but there was a significant increase in muscle density with corresponding decrease in collagen and elastin density in the walls of varicose veins compared with non-varicose vein controls.

Conclusions: There were no differences in the collagen or elastin content of varicose veins when compared with non-varicose veins. Smooth muscle hypertrophy occurs in varicose veins, which appears to disrupt the collagen/ elastin lattice of the vein wall.

Design: Single patient study.

Setting: Department of Dermatology; Teaching Hospital, Vienna, Austria.

Patient: A single patient with the rare condition of congenital absence of venous valves.

Interventions: Compression of the thigh using a thigh cuff.

Main outcome measures: Ambulatory venous pressure measurement.

Results: The ambulatory venous pressure was reduced when the thigh calf pressure was increased in excess of 70 mmHg.

Conclusion: Thigh compression in a patient with congenital absence of venous valves resulted in a temporary valve mechanism permitting orthograde flow during

muscle systole, but inhibiting venous reflux.

Design: Prospective controlled randomized trial.

Setting: Hospital outpatients and community ulcer clinics.

Patients: Sixty patients with chronic non-healing venous ulceration. Patients had either been treated for 12 weeks and their ulcer had failed to reduce by 20% of their original size, or had failed to completely heal within 24 weeks of treatment with the four-layer bandage.

Interventions: Patients continued treatment with the four-layer bandage, and randomized to receive either an occlusive dressing or a simple non-adherent (NA) dressing.

Main outcome measure: Time to complete healing analysed by life tables up to 12 weeks from randomization.

Results: At the end of the trial 43% of the patients randomized to an occlusive dressing and 23% to an NA dressing had completely healed. Life table analysis failed to show a significant difference (relative risk = 2.25; 95% confidence interval 0.88—5.75; p =0.077).

Conclusions: Good response of patients to an occlusive dressing has indicated the need for a larger study. A trial of 180 patients could detect a significant difference if crude rates are maintained in a larger study (80% power, 5% significance).

Design: Randomized parallel-group controlled trial, stratified by initial maximum ulcer diameter of 2—4 cm or >4 cm.

Setting: Community.

Patients: Five hundred and twenty-nine patients were assessed and 200 patients with clinical evidence of venous leg ulceration and initial ulcer diameter >2 cm were recruited to the trial. Patients with appreciable arterial disease (ratio of ankle to brachial systolic pressure <0.75) were excluded.

Interventions: Ulcers were treated with either Biofilm (a hydrocolloid dressing) or Betadine and Jelonet in the community for 4 months or until the ulcer healed, if sooner. All patients wore standardized graduated compression.

Main outcome measures: Time to complete healing of the ulcer, subjective assessment of pain and total cost of treatment.

Results: Healing was more rapid in patients using Biofilm dressing (relative risk 1.16, 95% confidence interval 0.8—1.8), but not significantly so p = 0.48. Patients’ subjective pain scores after 1 month of treatment indicated there was significantly less pain experienced by patients treated with Biofilm (p = 0.02). The total cost of treatment (including dressings and nursing time) was similar for Biofilm and Betadine for small ulcers (<6cm) but Biofilm cost three times as much for larger ulcers.

Conclusion: Provided that standardized graduated compression was used, the primary dressing did not significantly affect the time to complete healing of the ulcer.

Design: Single patient group.

Setting: District General Hospital, Edgware, Middlesex, UK.

Patients: Forty-one patients undergoing sapheno-popliteal ligation for varicose veins of the lower limb.

Interventions: Surgical exploration and ligation of the sapheno-popliteal junction.

Main outcome measures: Peroperative venographic demonstration of the short saphenous vein and sapheno-popliteal junction.

Results: Thirty-four sapheno-popliteal junctions (85%) lay at a site approachable by a conventional incision. Five junctions lay higher than this and one lower.

Conclusions: On-table venography is an efficient, quick and reliable way of demonstrating the anatomical site of the sapheno-popliteal junction.

Objective: To measure the abnormalities of venous function in patients with decompensated heart failure.

Design: Single group study.

Setting: Departments of Medicine and Surgery. Lund University Hospital, Lund, Sweden.

Patient: Forty-seven patients with decompensated heart failure due to myocardial insufficiency.

Interventions: Conventional medical treatment for decompensated heart failure. The application of graduated compression stockings randomly applied to one leg.

Main outcome measures: Strain gauge plethysmography assessment of venous capacitance and maximum venous outflow.

Results: Graduated compression stockings increased venous volume significantly, but did not influence maximum venous outflow.

Conclusion: The principal effect of compression stockings is probably a direct effect upon the veins in the leg in patients with decompensated heart failure.

Design: Prospective, randomized study of 44 subjects randomized to an SSVR group and a control group.

Setting: University Clinic, Chieti, and Angiology and Vascular Surgery Clinic, Pescara, Italy.

Patients: Twenty-two patients in the SSVR group and 22 in the control group. Inclusion criteria were incompetence of the sapheno-femoral junction (SFJ) with presence of valve cusps and two to five venous sites in the long saphenous vein.

Interventions: SFJ plication and selective interruption of the incompetent sites under general anaesthetic.

Main outcome measures: Ambulatory venous pressure measurements (refilling time) and colour duplex scanning to detect the number of incompetent sites.

Results: After 5 years, 18 patients in the SSVR group and 19 in the control group completed the study. SSVR increased refilling time (p<0.02) and the number of incompetent sites was decreased (p<0.02); in the control group, refilling time remained short and the number of incompetent sites increased (p<0.05).

Conclusion: SSVR is an effective treatment with good 5-year results on incompetence and the development of new incompetent venous sites.