CONTENTS  •  Volume 8  Number 4 1993

The article by Gradman on venoscopy in this issue demonstrates how modern technology may oblige us to revise our views on the development of venous disease, in particular valvular incompetence of the long saphenous vein. In many surgical textbooks it is suggested that valvular incompetence descends from the saphenofemoral junction to more distal parts of the saphenous vein. The article by Gradman shows that whilst terminal and subterminal valves of the long saphenous vein may he intact, those located more distally have already been completely destroyed. This suggests that a local process, specific to the valve cusps, results in valvular failure in the vein trunk before the onset of gross saphenofemoral junction incompetence. This is certainly contrary to the older theories of varicose vein development, which envisage that exposure of valves to high venous pressure results in their destruction. The findings in this study are consistent with those of colour duplex ultrasound imaging, which often shows incompetence in the long saphenous vein with a competent saphenofemoral junction. The implication of these observations may he that varicose veins are due to primary failure of the valves, and that the other pathological features of varicose veins such as venous dilatation and tortuosity of veins arc a consequence of this. These observations also suggest that management of varicose veins of the long saphenous system by treatment of the saphenofemoral junction alone, either by ligation or plication to restore valvular incompetence, may he doomed to failure owing to persisting incompetence of the long saphenous vein.

In the September 1993 issue of Phlebology (vol. K, pp. 116-9) Van Cleef described a studs using venoscopy in which he investigated valves at an earlier stage of incompetence than those reported by Gradman. He found incompetence resulting from widening of the valve commissures that could not be controlled by external compression. This raises the possibility that compression treatment in the case of varicose veins may not act by restoring valvular competence in the superficial veins, as is widely assumed. These observations are consistent with those from my own laboratory in which we could not restore valvular competence by external compression, when assessing the vein using colour duplex ultrasound imaging.

Introduction:  The cause of varicose veins still eludes explanation by modern phlebologists. Below I present my conclusions and model for treatment after practicing in the skill of compression sclerotherapy for 25 years and having considered the problem theoretically for a further 25 years. This concept has stood the test of time and has been in clinical practice [1,2], but has not been examined by modern methods of investigation such as duplex ultrasound imaging. This sequence of thoughts is presented as a challenge to modern phlebologists to verify or refute by scientific study.

Design: Prospective endovascular evaluation of greater and lesser saphenous veins during varicose vein surgery.

Setting: Cedars-Sinai Medical Center, Los Angeles, California, USA.

Patients: Thirty-one limbs in 25 patients undergoing varicose vein surgery.

Intervention: Patients underwent retrograde passage of a 2.3 mm angioscope from the junction of the saphenous and deep vein distally to the first competent valve.

Main outcome measures: Based on intraoperative findings, the greater saphenous vein was preserved in eight out of 25 cases. Preoperative assessment of lesser saphenous reflux was incorrect in three out of six cases.

Results: An incompetent subterminal valve was found in 16 out of 25 greater saphenous veins. In 13 out of 25 limbs, no other valves were seen to the knee. Four patients had competent thigh valves.

Conclusions: Retrograde venoscopy may be of benefit in varicose vein surgery.

Patients: Thirteen legs in patients with venous ulceration were compared with seven legs in patients suffering from lipodermatosclerosis (LDS) only and nine normal controls.

Design: Leg and arm venous blood samples were obtained from each patient after a period of 30 mm of leg dependency followed by elevation to the horizontal for a further 5 mm. Neutrophils were isolated and free radical production assessed by luminol-depcndent chemiluminescence following stimulation with the chemotactic peptide FMLP.

Results: The ratio of leg to arm luminescence was significantly higher in patients with venous ulceration (median 1.61; 95% confidence interval (CI) 1.20-3.05; p=O.0002) and those with LDS (median 1.36; 95% CI 1.05-2.01; p=0.0036) when compared with the controls (median 0.97; 95% CI 0.70-1.12).

Conclusions: Neutrophil free radical production is increased in the legs of patients with venous hypertension and may be implicated in the underlying pathogenesis of this disease.

Design: Measurement of maternal and fetal heart rate and uterine artery flow velocity (Vmax) in supine and standing positions with and without graduated compression hosiery (25 mmHg at the ankle).

Setting: Department of Surgery, Lund University, S-22185 Lund, Sweden.

Patients: Eighteen women in gestational week 32—38.

Results: An increase in heart rate on standing was recorded for both mother and fetus. Graduated compression stockings decreased these changes. Cyclic heart rate changes were not frequent. Uterine artery flow velocity did not change during change of posture or after compression.

Conclusion: The utero-vascular syndrome was not common in the patients studied. Graduated compression reduced the vascular response to standing, measured as an increase of heart frequency at standing.

Design and technique: Routine ultrasound colour duplex scanning during a 6-month period.

Patients: Three hundred and two inpatients and outpatients investigated on suspicion of DVT.

Setting: Department of Clinical Physiology, which is the central non-invasive diagnostic unit of the county.

Results: A diagnosis of DVT was made in 33%. EVM were detected in 14 patients (5%). In most cases the characteristic appearance on scanning was spindle-shaped (like a ‘mouse’) and mostly confined to the upper calf. These EVM were regarded as intramuscular haematoma or ruptured popliteal cysts.

Conclusion: EVM of the leg are (1) a frequent cause of ‘pseudothrombosis’ and can positively be identified by duplex ultrasound scanning: (2) most frequently found in the medial aspect of the right calf; and (3) often detected in patients with rheumatoid arthritis or patients on anticoagulant therapy and may give rise to signs and symptoms identical to DVT.

Design: Adaptation of a standard optical leg volume meter, ‘volometer’. and calibration on an artificial leg and on volunteers. Study of the behaviour of lower leg volume in volunteers.

Setting: Free University Hospital. Amsterdam.

Participants: Thirty-six healthy volunteers, workers in the hospital.

Intervention: The lower leg volume was measured on five or six different days at the beginning and end of a full working day.

Main outcome measures: Reproducibility of the adapted volometer, and volume changes of the lower legs at different times.

Results: Adaptation of the volometer resulted in a reproducibility of 0.07%. in an artificial leg and of 0.46% in volunteers. A significant increase (p.<0.0001) in the volume of the lower legs in the course of the day was observed.

Conclusion: Adaptation of the optical leg volume meter resulted in reproducible recordings of the volume of lower legs. In the course of the day an increase in volume occurs.

Design: Retrospective study of cases found during the period from 1986 to 1991.

Setting: University Hospital of the Military School of Medicine, Bogota, Colombia.

Patients: Twelve patients, Ii unilateral and one bilateral, representing 0.5% of our total experience in surgery of varicose veins in 5 years.

Interventions: Surgical resection of the angiomatous malformation.

Main outcome measures: Clinical assessment of patients and histological examination of excised tissue.

Results: The excised angiomatous tissue was found to contain irregular venous vessels, associated with lymphatic nodular structures and surrounded h adipose tissue. A satisfactory clinical outcome was obtained in patients where the angiomatous tissue could be excised.

Conclusions: Vascular surgeons treating varicose veins should be aware of the possibility of finding vascular angiomatous malformation of the saphenofemoral junction. Surgical resection of these benign lesions results in a satisfactory clinical outcome.

Design: Preliminary report on 83 cases.

Patients: Seventy-five patients with incompetence of the SSV or LSV.

Interventions: Forty-two partial strippings and one complete stripping of the SSV; 40 strippings of segments of the LSV.

Results: The method described (‘Pin-stripping’) permits stripping without visualization of the distal end of the vein. Removal of the vein is possible through a stab incision and is feasible under local anaesthesia. Operation time is reduced and no postoperative complication was seen.

Conclusions: Compared with conventional strippings, ‘Pin-stripping’ offers several advantages in removing segments of the LSV or SSV.