CONTENTS  •  Volume 8  Number 1 1993

I have read many articles that include a phrase such as ‘measurement of ambulatory foot vein pressure in the "gold standard" of assessment in patients with venous disease’. Perhaps it is significant that the use of the monetary Gold Standard to which the phrase refers has long since been discarded. However, recent events within its European successor, the European Monetary System, suggest that whatever the deficiencies of gold standards, their successor may not provide an improved reference standard. Four articles in this issue (by Moulton et al., de Palma et al., Beckwith et al. and Kalodiki et al.) address different aspects of the measurement capabilities of duplex ultrasound imaging systems. The study by Beckwith et al. shows that the pulsed Doppler systems used in duplex ultrasound machines are capable of measuring flow accurately in a model system. Reliable indication of the amount of reflux may he assessed. Interestingly, the study of Moulton et al. shows that the clinical findings in patients with venous disease do not correlate well with the quantitative measurements made by a duplex ultrasound machine. This is clearly disappointing, since the cost of such equipment greatly exceeds that of the foot vein pressure measuring systems. Examination of the published literature in the field of foot vein pressure measurement also shows a wide scatter of results within clinically assigned groups (e.g. uncomplicated varicose veins, trophic skin changes, ulceration). suggesting that a number of other factors not measured by either duplex ultrasound examination or foot vein pressures are important in determining the clinical outcome. Perhaps we disregard the behaviour of our patients in response to our recommendations. Some patients may diligently obey our instructions and rest with their legs elevated, some may sit with their feet dependent throughout the day. Some may wear stockings. others may find them intolerable. So vascular laboratory investigation may not provide the final answer in assessing the response to venous valvular incompetence, however precisely this may he measured.

Nevertheless, the paper by de Palma et al. demonstrates the value of ultrasound imaging in the surgical treatment of patients with venous disease. In this paper the authors have compared a hand-held Doppler system with colour duplex ultrasound imaging. Enthusiasts of the pocket Doppler may be a little dismayed to learn how many incompetent veins they might be missing. The discrepancy in results is perhaps not surprising in view of the much greater cost of the duplex system. Modern systems have been designed, with the encouragement of clinicians interested in the assessment of venous disease, to provide machines capable of ever lower velocity measurement. Machines currently in use will detect flow velocities of only a few millimetres per second. Pocket Dopplers cannot compete with such precision. This raises the question of how much reflux is necessary to call a vein ‘incompetent’, and perhaps submit this vessel to surgical excision. Published results suggest that a normal lower limb vein will permit reverse flow for only a short period (up to 0.5 s) following rapid release of calf compression. It is unclear whether all veins that exhibit reverse flow under these circumstances should be defined as incompetent, and potential candidates to develop varicosities. The Bochum studies have shown that venous valvular incompetence may be detected in a proportion of school children, and that definite varicosities may develop in the teenage years. The fate of a normal-sized vein in an adult when low velocity reflux has been shown is unclear, since no study has been published in which this has been followed over an extended period.

Design: A prospective study in a single group of patients with venous insufficiency.

Setting: Private practice in secondary and tertiary care.

Patients: 133 inpatients undergoing investigation for venous disease. Patients with known venous obstruction, arterio-venous malformations or lymphoedema were excluded from the study.

Main outcome measures: Duplex ultrasound scanning was performed to measure the cross-sectional area, severity and duration of venous reflux following calf compression using a standardized technique.

Results: Clinical classification assigned to each limb correlated with the presence of venous reflux, hut not the quantity, velocity or duration of reflux in the veins studied. Presence of reflux and diameter of the vein studied correlated (p<0.00l) in all the veins except the popliteal vein (p>0.0³).

Conclusion: Quantification of venous reflux obtained by cuff deflation does not correlate with clinical severity of venous stasis, but does detect reflux accurately. This allowed greater saphenous sparing in nine limbs in 41 patients but proved the need for saphenous removal in seven limbs not previously suspected clinically of requiring this procedure.

Design: Prospective performance of PE and CWD by two clinical examiners and subsequent duplex scanning by two vascular laboratory technicians unaware of the results of the PE and CWD examinations. Tapes were then reviewed; results of the duplex scanning were compared with physical and CWD findings.

Patients: Thirty-one women and nine men, aged 27-64 years, with symptomatic class I primary varicosities in distribution of the GSV. Eighty limbs were evaluated prospectively in 40 consecutive patients, including 22 limbs in 14 patients with a history of prior GSV stripping.

Interventions: GSV ligation and stripping in 50 limbs when duplex demonstrated sapheno-femoral or truncal reflux; 30 limbs were treated by stab avulsion, cluster excision and sclerotherapy.

Main outcome measures: Demonstration of sapheno-femoral reflux by duplex was confirmed by operative findings. Sensitivity, specificity and positive and negative predictive values of PE and CWD were calculated in comparison to duplex scans.

Results: For PE, sensitivity ad specificity were 48% and 73%; positive predictive and negative predictive values were 75% and 46%. For CWD, sensitivity and specificity were 48% and 83% positive predictive and negative predictive values were 83% and 44%. CWD was falsely positive for sapheno-femoral reflux in 10 instances, The GSV was spared in these 10 limbs and in 20 other limbs based on negative colour flow duplex examinations. At 12-18 months clinical results were similar in 50 limbs treated by ligation and GSV stripping as compared with 30 treated by stab avulsion, cluster and sclerotherapy.

Conclusion: Sensitivity and negative predictive values for PE and CWD were low while specificity and positive predictive values were high. CWD false positives were due to insonation of veins close to the bulb or upper superficial femoral vein reflux subsequently detected by duplex scans. Colour flow duplex scanning is recommended prior to intervention for primary saphenous varicosities; exceptions occur in slender subjects where PE and CWD arc more specific and predictive for reflux.

Design: Pearson’s correlation and zero line assessment were used. Using a phantom, multiple tests were performed so that a wide spectrum of flow volumes could be compared with corresponding Doppler waves.

Setting: Private diagnostic imaging clinic with vascular surgical association.

Main outcome measures: The hypothesis was that there should he a significant correlation between the Doppler wave and the blood flow volume and, in particular. the Doppler area.

Results: The Doppler wave index EI_d demonstrated the highest correlation coefficient (r = 0.97, p<0.0l) when compared with the volume index El_v..

Conclusion: While there is a strong correlation between EI_d and flow volume, additional study is needed to determine its place in the clinical setting.

Design: Single patient group, comparison of duplex ultrasound imaging with phlebography.

Setting: Teaching hospital vascular laboratory.

Patients: Patients referred for assessment of their venous system.

Main outcome measures: Duplex ultrasound scanning of the lower limb, ascending phlebography.

Results: Our results of duplex ultrasound scanning in the diagnosis of deep vein thrombosis as compared with phlebography show a sensitivity of 94% and a specificity of 91%.

Conclusions: We found it advantageous to examine the patient standing during proximal vein imaging and sitting for distal venous examination. Veins dilated as a result of gravitational effects arc visualized more easily. The examiner, by resting the elbow on his/her distal thigh, has a more stable hand, facilitating the test. The patient, by resting the heel on the edge of the examiner’s chair, relaxes the calf muscles, thus simplifying the augmentation manoeuvre. The inflation of a tourniquet applied to the distal thigh dilates the calf veins.

Design: Prospective, randomized study of 164 patients. The patients were assessed with clinical tests and foot volumetry, before the 6 months, 1, 3 and 5 years after treatment.

Setting: Department of Surgery, University of Lund, Sweden.

Patients: 164 patients referred to the clinic for treatment of symptomatic primary varicose veins. Eighty patients were randomized to surgery and 84 to (‘ST.

Interventions: Sclerotherapy was applied using the ‘empty vein’ technique followed by compression bandage for 6 weeks. The extent of surgery was determined by each patient’s disease and included flush ligation of the long or short saphenous veins and subsequent stripping, ligation of incompetent perforating veins and resection of local varicosities.

Main outcome measures: The recurrence rate of varicose veins and incompetence of perforators and saphenous veins.

Results: Good results were achieved in both treatment groups immediately after the procedure, hut the failures appeared earlier in the CST group and the number was higher compared with the surgery group. After 5 years only 10% of the operated patients were considered as treatment failures compared with 74% of the patients treated with CST. The clinical results were supported by the foot volumetry measurements.

Conclusions: This study clearly indicates that patients with primary varicose veins and incompetent saphenous veins should be treated with surgery, and CST should be confined to local varicosities, isolated insufficient perforators or recurrences after adequate surgery.

Design: Prospective study in varicose vein patients treated by injection-compression sclerotherapy.

Setting: Outpatient Surgery Clinic. University of California San Diego, La Jolla, California.

Patients: Patients presenting with varicose veins on the lower thigh and below.

Interventions: Patients underwent injection-compression sclerotherapy. Needles insertion was done with the patient in a horizontal position after veins were distended using a large contoured thigh cuff.

Main outcome measures: Successful vein distension and needle insertion.

Results: Ninety-five percent of patients had adequate vein distension for needle insertion.

Conclusion: Vein distension, prior to needle insertion for sclerotherapy can he achieved by using a large contoured thigh cuff.

Design: Prospective single patient group study (22 consecutive patients).

Setting: University College Hospital (Teaching Hospital).

Intervention: Loco-regional and general anaesthesia. Non-opiate analgesia. Surgical treatment for varicose veins.

Main outcome measures: Patient interview, pain scores, analgesia requirement.

Results: Post operative pain was absent in 36% during the first 24 hours. Oral analgesia was given to 36% as in-patients but only l8% after discharge. Before surgery, 95% would have preferred DCS hut only 24% at six months. The after-effects of general anaesthesia was the main reason for this change in attitude.

Conclusions: Patients would like day case surgery for varicose veins but anaesthesia and analgesia must be satisfactory.

Interventions: Long saphenous vein stripping using a modified standard stripping device.

Conclusions: The modified stripper provides a satisfactory method of removing the long saphenous vein without resulting in large scars.

Design: Case report.

Setting: Edgware General Hospital, Edgware. Middlesex.

Patients: Three patients presenting with Marjolin’s ulcer.

Interventions: Amputation (2 cases) and excision with skin grafting (1 case).

Main outcome measures: Disease control.

Results: Satisfactory control of disease in all three.