CONTENTS  •  Volume 8  Number 3 1993

Editorial

A Personal View

Original Articles

99 Microangiopathy in Chronic Venous Insufficiency Before and After Sclerotherapy and Compression Treatment: Results of a One-Year Follow-up Study
A. J. Leu, A. Yanar, M. Geiger, U. K. Franzeck and A. Bollinger

107 Endothelium-derived Relaxing Factor Release from Normal and Varicose Human Saphenous Veins
S. P. K. Payne, R. D. Sayers, P. A. C. Watt, P. R. F. Bell and H. Thurston

111 The Role of Elastic Compression Stockings in Prevention of Venous Dilatation Induced by a Reverse Trendelenburg Position
J. I. Arcelus, J. A. Caprini, C. I. Traverso, G. Size and J. H. Hasty

116 Valves in Varicose Veins and External Compression Studied by Angioscopy
J. F. Van Cleef

120 Comparison of Clinical and Photoplethysmographic Assessment of Venous Insufficiency
A. Kurgan, L. B. Lerenbuch, S. D. Gertz, J. Shapiro, B. Ofek, D. Shemesh and H. B. Abramowitz

124 Venous Reflux Localization: Comparative Study of Venography and Duplex Scanning
L. I. Va/entIn, W. H. Valentin, S. Mercado and C. J. Rosado

128 Long-term Clinical Results Following Correction of Incompetent Superficial and Perforating Veins in Patients with Deep Venous Incompetence and Ulcers
H. Åkesson

Meeting Report

Letters

Case Report

Announcements

Book Reviews

119
135

PD Coleridge Smith

It has been known for decades that deep vein thrombosis (DVT) may ensue after many types of surgical procedure. Numerous methods have been evaluated for preventing this problem, and there are now several methods that may be used to prevent unnecessary deaths and post-phlebitic limbs. Despite this, patients still suffer fatal pulmonary emboli in hospital, even when there is appropriate usage of prophylactic measures [1]. Whilst there has been substantial expansion in the knowledge of the mechanisms that result in the formation of thrombus from the clotting components of the blood, advances in the understanding of reasons for post-operative DVT have been much less rapid. The endothelium of the deep veins of the lower limb has proved difficult to evaluate in human subjects during surgical procedures.

Recent changes in surgical practice pose new problems. We are encouraged to perform surgical procedures with ever-shorter hospital stays, and there is now an increasing enthusiasm for day case surgery. In a study carried out a few years ago we showed that a significant proportion of patients developed a DVT after discharge from hospital [2]. A consequence of early hospital discharge may be that patients are exposed to the risk of DVT without receiving any prophylactic measures. Several studies are now in progress to assess the efficacy of implementing methods of prophylaxis that may be used by patients at home. The results of such studies may change our current practices in using preventive measures.

The increasing use of laparoscopic surgery also seems likely to change surgical practice in the field of abdominal surgery. This technique has been widely adopted as the method of choice in performing cholecystectomy and is now being used to carry out several other general surgical procedures that would previously have been undertaken at laparotomy. The incidence of DVT following laparoscopic surgery has not been assessed in a systematic way, although reports in journals of laparoscopic surgery document several cases. There are several reasons why laparoscopic surgery may predispose to DVT. Increased operation time, abdominal insufflation and the use of the reverse Trendelenburg position, which may result in venous distension and pooling in the lower limbs, are all factors that may contribute to the development of a DVT. These are discussed by Arcelus et al. in their article on this subject in this issue, where they present a possible strategy for reducing venous distension in the lower limbs. Clearly this subject necessitates more study to determine the degree of risk to which patients arc exposed during laparoscopic surgery. as well as to establish the efficacy of conventional methods of prophylaxis. if the number of laparoscopic procedures increases in other countries as it has done in the USA, large numbers of patients may be exposed to an undefined risk of thrombosis. They may recover rapidly from their surgery, only to be incapacitated by a DVT.

References

1. Linblad B. Sternby NH. Bergqvist D. Incidence of venous thromboembolism verified by necroscopy over 30 years. Br Med J 1991:302:709-11.

2. Scurr JH. Coleridge Smith PD, Hasty JH. Deep venous thrombosis: a continuing problem. Br Med J 1988;297:28.

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A. J. Leu, A. Yanar, M. Geiger, U. K. Franzeck and A. Bollinger 
Department of Internal Medicine, Angiology Division. University hospital, CH-8091 Zurich, Switzerland

Objective: To characterize microangiopathy in patients with chronic venous insufficiency (CVI) of a moderate to severe stage and to evaluate improvement of the microcirculatory parameters after sclerotherapy of incompetent perforators and compression therapy.

Design: Fluorescence videomicroscopy (Na-fluorescein), laser Doppler fluxmetry and tcPo₂ measurements (43°C) at the medial ankle in healthy controls and patients. Laser Doppler flux and tcPo₂ were recorded in supine and sitting position in order to evaluate postural vasoconstriction. The measurements were repeated 6 and 12 months after sclerotherapy of incompetent perforators (Polidocanol 40 mg/ml) and compression therapy by below-knee class ii or III stockings (Sigvaris®).

Setting: Department of Internal Medicine. Angiology Division, University Hospital, Zurich, Switzerland.

Patients, participants: 15 healthy subjects (15 legs, mean age 53.3 years) and 15 patients with CVI of a moderate to severe stage (17 legs, mean age 56.8 years).

Results: Microangiopathy in CVI is characterized by significantly enlarged, elongated and dilated capillaries with increased diameters of the pericapillary spaces (‘halos’). Single capillaries may be thrombosed. Laser Doppler flux is increased and tcPo₂ is decreased. After therapy, there was a trend to decreased laser Doppler flux and an increase in tcPo₂, but the differences were not statistically significant. Capillary thromboses were no longer detected. Mean halo diameters tended to decrease, but this difference was not statistically significant.

Conclusions: Microangiopathy in CVI is characterized by morphological and functional changes. Beneficial changes induced by therapy develop slowly and emphasize the importance of long-lasting treatment.

Keywords: Chronic venous insufficiency; Compression treatment; Fluorescence videomicroscopy; Laser Doppler fluxmetry; Sclerotherapy; tcPo₂ measurements

Correspondence and offprint requests to: Professor Dr A. Bollinger, Department of Internal Medicine, Angiology Division, University Hospital, CH-8091 Zurich, Switzerland.

Contents

S. P. K. Payne¹, R. D. Sayers¹, P. A. C. Watt², P. R. F. Bell¹ and H. Thurston²
Departments of ¹Surgery and ²Medicine, Clinical Sciences Building, Leicester Royal infirmary, P0 Box 65, Leicester, LE2 7LX, UK

Objective: To evaluate the role of endothelium-derived relaxing factor (EDRF) in the regulation of smooth muscle tone in normal and varicose human saphenous veins.

Design: An in vitro study of site-matched saphenous vein samples from patients undergoing varicose vein surgery or carotid endarterectomy.

Setting: Department of Surgery, University of Leicester, Leicester Royal Infirmary.

Patients: Nine patients undergoing varicose vein surgery and seven patients undergoing carotid endarterectomy.

Measurements: Vein samples were contracted with noradrenaline and relaxation studies performed with acetyicholine (endothelium-dependent) and sodium nitroprusside (endothclium-independent).

Results: There was no statistical difference in either smooth muscle contraction in response to noradrenaline or in endothelial-dependent relaxation in response to acetyicholine. All veins retained the ability to relax in response to nitroprusside.

Conclusions: No evidence of a defect in either smooth muscle function or EDRF release has been found that may contribute to the aetiology of varicose veins.

Correspondence and offprint requests to: S. P. K. Payne. Nuffield Department of Surgery. John Radcliffe Hospital, Headington, Oxford 0X3 9DU, UK.

Contents

J. I. Arcelus, J. A. Caprini, C. I. Traverso, G. Size and J. H. Hasty
Department of Surgery, The Glenbrook Hospital, Glenview, Illinois, and Northwestern University Medical School, Chicago, Illinois, USA

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J. F. Van Cleef
45 Rue de Ia Chaussee d’Antin, F-75009 Paris. France

Aim: To explain the mechanism of action of external compression in venous/valvular incompetence

Design: Prospective investigation in single patient group.

Setting: Notre Dame de Bon Secours Hospital. Paris, France.

Patients: Four patients presenting with primary varicosities undergoing surgical treatment.

Interventions: Dynamic saphenous vein angioscopv with application of external compression to the limb.

Main outcome measures: Angioscopy assessment of venous valvular incompetence.

Results: External compression failed to abolish reflux in valves where there was an intercorneal space at the valve commissure.

Keywords: Compression; Hosiery: Long saphenous vein; Venous Valves; Venous valvular insufficiency

Contents

A. Kurgan ^1,2, L. B. Lerenbuch¹, S. D. Gertz ^1,2, J. Shapiro¹, B. Ofek¹, D. Shemesh¹ and H. B. Abramowitz^1
1Department of Surgery B, Vascular Institute, Shaare Zedek Hospital and ²Department of Anatomy and Embryology, The Hebrew University, Hadassah Medical School, Jerusalem, Israel.

Objective: To assess the concordance between clinical and photoplethysmographic evaluation of venous insufficiency.

Design: Comparison of two methods of evaluation of venous insufficiency in randomly selected patients.

Setting: The Vascular Institute, Shaare Zedek Hospital, Jerusalem, Israel.

Patients: Four hundred patients selected at random from a pool of 3000 patients referred to the vascular institute for suspected venous insufficiency.

Interventions: Each of the 800 legs was evaluated clinically, by Trendelenburg testing, and by venous reflux photoplethysmography (VPPG).

Results: Of 230 legs without clinical evidence of venous insufficiency (including Trendelenburg testing). 214 (93%) were also normal by VPPG. However, of 359 legs with clinical evidence of venous insufficiency, only 178 (50%) were so confirmed by VPPG. Of 135 legs considered to have insufficiency of the deep venous system (DVI) by clinical criteria alone, only 31(23%) were confirmed to have DVI by VPPG, and 49 (36%) were found by VPPG to have insufficiency of only the superficial system.

Conclusions: Reliance upon clinical assessment alone is inadequate for distinguishing between insufficiency of the deep and superficial or perforating venous systems. Assessment by VPPG may identify many patients with dermatologic changes "typical of DVI" who may benefit from superficial venous surgery.

Keywords: Photoplethysmography; Varicose veins; Venous insufficiency

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L. I. Valentín, W. H. Valentín, S. Mercado and C. J. Rosado
Instituto Vascular de Puerto Rico, Bayamón, Puerto Rico, West Indies

Objective: To compare the results obtained by duplex ultrasound imaging and ascending and descending phlebography in patients with chronic venous insufficiency.

Design: Prospective comparison between venography and duplex ultrasound imaging in a single patient group with chronic venous insufficiency.

Setting: Private vascular clinic in Puerto Rico.

Patients: Twenty-one patients presenting with clinical evidence of venous disease of the lower limb.

Main outcome measures: Presence of valvular incompetence in deep and superficial veins as indicated by duplex ultrasound imaging and ascending and descending phlebography.

Results: Duplex ultrasound imaging showed twice as many patients with popliteal vein incompetence (eight veins compared with four veins) and twice as many incompetent long saphenous veins (14 detected by duplex, eight detected by venography). In the proximal venous system, 13 common femoral veins were thought incompetent on venography, but only seven on duplex scanning; in the superficial femoral vein, 11 were incompetent on venography and three on duplex scanning.

Conclusion: Duplex ultrasound scanning provides greater sensitivity for detection of valvular incompetence in distal veins compared with venography. Descending phlebography is poor in demonstrating distal venous valvular incompetence.

Keywords: Ascending and descending venography; Chronic venous insufficiency; Duplex ultrasound imaging; Investigation; Varicose veins

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H. Åkesson
Department of Surgery. Malmö General Hospital, S-214 01 Malmö, Sweden

Objectives: To assess the presence of venous ulcers following stripping of the saphenous vein and ligation of perforating veins in patients with deep venous incompetence.

Design: Retrospective follow-up after a median of 41 months following surgery.

Patients: Thirty operated limbs in 25 patients with venous ulcers, originally entering a prospective study of physiological changes following surgery for venous insufficiency.

Interventions: An interview regarding absence of ulcers, expressed as a percentage of the follow-up time after surgery - the ‘ulcer-free period’. Correlation with ambulatory venous pressure (AVP) and foot volumetric measures following surgery.

Main outcome measures: The presence or absence of venous ulcers.

Results: The ulcer-free period for the whole group was 76%. There was a significant (p<0.05) difference in the ulcer-free period in limbs with an AVP below 60 mmHg (89%) compared with limbs with a higher AVP (70%).

Conclusion: Failure to normalize AVP with surgery results in persistent high venous pressure and an increased risk of venous ulceration recurrences.

Keywords: Ambulatory venous pressure; Chronic venous insufficiency; Ligation of perforating veins; Long-term results; Saphenous stripping; Venous leg ulcers

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Copyright © 2000 Philip Coleridge Smith