CONTENTS  •  Volume 8  Number 2 1993

It has been interesting to see the progress of phlebology as a science and clinical practice in continental Europe and its development in the UK. There are diverse practices in this specialty in different parts of Europe. In France, where phlebology has long been established, there are those who confine themselves to sclerotherapy and others who combine surgical treatment with sclerotherapy. In many parts of Europe, venous diseases are dealt with by dermatologists, some with a surgical training in vascular or plastic surgery, who have the skills to perform any of the standard surgical procedures in venous disease. In the UK, venous diseases have remained in the domain of the general or vascular surgeon. Vascular surgical training is not available for dermatologists, who would never consider performing surgical procedures for the management of varicose veins.

In this context it is fascinating to watch the growing interest in phlebology in the USA. Published data suggest that the prevalence of venous disease in the USA is very similar to that in Europe, and yet until recently there has been little attention given to the study of phlebology in the USA. The evolution of two societies has changed the American viewpoint considerably. The American Venous Forum held its inaugural meeting in 1989 in New Orleans. Modelled on the Venous Forum of the Royal Society of Medicine, the founding executive committee, largely comprising vascular surgeons, decided that the American Venous Forum should strive for scientific advance in the field of phlebology. Remarkably little basic research is undertaken in this field considering the high prevalence of venous disease in western countries, and the support of an American society in this field is very welcome. The North American Society of Phlebology (NASP), which held its first Annual Congress in 1988, initially comprised chiefly dermatologists who were mainly interested in sclerotherapy techniques. Thanks to the energies of the scientific committee of this society, the membership now comprises practitioners with a much broader range of interests and many vascular surgeons are now included in the membership. The scope of the meetings of this society is also very broadly based, covering many aspects of venous disease. The NASP has also held many training meetings to ensure that investigation and treatment skills in phlebology are properly taught. There is no doubt that modern vascular laboratory techniques are invaluable in the management of patients with complex venous disease, and yet there are few centres with expertise in this field. This society is to be congratulated on its efforts to improve the quality of patient care offered by its members.

Design: Single patient group.

Setting: Unite de Pathologic Vasculaire Jean Kunlin, Clinique du Grand-Large. av. Leon-Blum, Decines Charpieu, France.

Patients: Fifty-three patients with clinical and radiological evidence of post-thrombotic syndrome uncontrolled by conventional conservative treatment.

Interventions: Surgical restoration of deep vein competence by one of four methods: valvuloplasty, vein transplantation, vein transposition, or Psathakis’ sling procedure.

Main outcome measures: Sustained ulcer healing, photoplethysmography (PPG) refilling times, abolition of venous reflux on duplex scanning, symptomatic improvement.

Results: All four techniques led to sustained ulcer healing in approximately two-thirds of patients. There was a poor correlation between maintenance of ulcer healing and improvement in PPG refilling times or abolition of reflux on duplex ultrasound.

Design: A paired study of affected and unaffected calf muscle in seven patients with unilateral lower limb deep venous insufficiency.

Investigations: Phosphorus-31 magnetic resonance spectroscopy was used to study changes in vivo in pH, phosphocreatine and other phosphorus metabolites during and after exercise.

Results: Glycolytic activity was increased in the affected muscle at the start of exercise but metabolic recovery following exercise was normal.

Conclusions: Oxidative phosphorylation is impaired, at least at the start of exercise, but appears normal immediately after exercise. This may be due to inadequate blood flow, perhaps secondary to the rise in intramuscular pressure that occurs with exercise.

Design: Follow-up study of patients 6 years after an episode of suspected symptomatic DVT.

Setting: Vascular laboratory, University Hospital of Lund.

Patients: 66 patients, 19 with femoral DVT, 20 with calf DVT and 27 with normal phlebograms at initial investigation.

Main outcome measures: Symptoms and signs of chronic venous insufficiency (CVI), foot volumetry and measurement of plasminogen activator inhibitor 1 (PAI-1) activity. Initial clinical signs and results at phlebography were compared with findings at follow-up.

Results: Of patients with DVT, 11(28%) had been treated for a recurrent DVT during follow-up. No relation was found between initial signs of DVT and late signs of CVI. Patients with DVT had significantly more signs of CVI but symptoms did not differ between the groups. Mean levels of PA I-1 activity were similar in the three groups, and patients with recurrent DVT did not differ. Refilling flow was related to the clinical CVI-score, and expelled volume was inversely related to the extension of DVT at phlebography.

Conclusion: The recurrence rate is high in first-time DVT, hut symptoms are mostly mild as long as after 6 years. There is a poor correlation between symptoms of CVI and objective findings. The late development of CVI cannot be predicted from the clinical signs in the acute phase. Levels of PAI-1 do not correlate with the degree of CVI.

Design: Single patient group with treatment crossover.

Setting: Department of Surgery, University College and Middlesex Hospital, London, UK.

Subjects: Thirty-four limbs of 17 normal adult volunteers were studied.

Interventions: Sequential gradient compression was applied to one leg and single-chamber compression to the other lower limb for 10 mm. The compression devices were then swapped to the opposite leg for a further 10 mm period.

Outcome measures: The increase in foot volume (distal venous distension) in response to each compression, and the subsequent decrease in foot volume (distal venous emptying), were measured. The overall reduction of foot volume (net effect) during the period of compression was calculated.

Results: The results indicate the net effect was a decrease in foot volume (median decrease 0.35 ml%, 95% CI: 0.21% to 0.45%) with the SCD and no change with the Venodyne (median decrease 0.09 ml%, 95% Cl: -0.25% to 0.22%).

Conclusion: We conclude that sequential intermittent pneumatic compression of the calf and thigh is less likely to cause distal blood trapping and foot swelling than single-chamber calf compression.

Design: Parallel groups study comparing patients with chronic venous insufficiency with control subjects.

Setting: Vascular laboratory, Middlesex Hospital, University College and Middlesex School of Medicine, London, UK.

Participants: Twenty patients with lipodermatosclerosis and chronic venous insufficiency comprised the disease group, and 15 subjects without venous disease comprised the control group.

Main outcome measures: The skin temperature, LDF, CMBC and SBC were assessed in the gaiter area and on the dorsum of the foot.

Results: A higher LDF (median LDF and interquartile range (IOR) = 132 (66-289), p = 0.001 (Mann-Whitney) and skin temperature (Median temperature and IQR = 31.1 (29.6-32.4), p = 0.001) was found in the liposclerotic skin of patients with chronic venous insufficiency compared with normal controls (median LDF and IOR = 49 (32-58); median temperature and IQR = 28 (27-30.3)). Similarly the LDF on the dorsum of the foot (median LDF and IQR = 73 (59-127). p = 0.03) and skin temperature on the dorsum of the foot (median temperature and IQR = 31.1 (30.4-32.1), p = 0.002) was significantly higher in the patients with chronic venous insufficiency compared with normal controls (median LDF and IQR = 55 (36-66), median temperature and IQR = 29.5 (26.7-30.7)).

Conclusions: This study demonstrates that there is increased skin blood flow in both liposclerotic skin and clinically normal skin in patients with chronic venous insufficiency.

Design: A prospective double-blind, randomized, parallel, placebo-controlled trial.

Setting: Surgical department of a regional hospital.

Patients: Forty patients undergoing venous surgery for varices associated with superficial insufficiency.

Interventions: Sapheno-femoral ligation, stripping of the entire long saphenous vein and removal of varicosities via 0.5 cm incisions. HR was given at 2 g/day (or placebo) for 6 weeks starting on the first postoperative day. Twenty patients were randomized to each group.

Main outcome measures: Leg volumes were measured by an automatic electronic-optic volumeter, prior to operation and again after 6 weeks and 3 months. Leg symptoms were recorded on days 1 and 10, weeks 3 and 6, and at 3 months.

Results: There was no difference in leg volume between the two groups during the first 6 weeks when stockings were worn, but the increase in oedema of the distal leg in the subsequent 6 weeks was significantly less in the FIR group. Symptoms disappeared rapidly 3 weeks postoperatively in both groups.

Conclusions: Stockings are effective in controlling postoperative leg oedema and symptoms. The addition of HR can prevent subsequent oedema after removal of the stockings.

Setting: Unite de Pathologic Vasculaire Jean Kunlin, Clinique du Grand-Large, av. Leon-Blum, Decines Charpieu, France.

Patients: Five patients with radiological evidence of venous aneurysm in the popliteal fossa.

Interventions: Surgical repair in all cases.

Main outcome measures: Avoidance of pulmonary embolism.

Results: Satisfactory postoperative recovery in all. No complications or subsequent pulmonary emboli.