CONTENTS  •  Volume 9  Number 4 1994

In recent issues of Phlebology I have discussed developments in the pharmacological treatment of venous diseases. In this issue four authors present reports of surgical methods for treating incompetent veins. Three manuscripts refer to external banding valvuloplasty of superficial or deep veins in restoring valve competence. This is clearly a very appealing option in treating deep vein incompetence. Open valvuloplasty of the type originally described by Kistner is a major undertaking in elderly patients and is often discarded for this reason when dealing with the majority of patients. External valvuloplasty offers the hope of restoring valvular competence without the necessity of such a radical approach, perhaps opening the options for surgical treatment to patients who would not be considered fit for a major vascular procedure. The use of an external band to reduce the diameter of the vein in order to restore competence implies that valvular incompetence is attributable to venous wall dilation, rather than degeneration of the valves. If this assumption is really correct, then such techniques may offer the possibility of long-term restoration of competence to deep vein valves. The prosthetic material never comes in contact with the blood, reducing the likelihood of deep vein thrombosis following such operations. a potential problem with open valve repair procedures. In addition the presence of the external band permanently prevents vein dilation, increasing the likelihood of long term efficacy. It is clear from the paper by Guanera et al. that this technique is effective in restoring valve competence, however, long-term (5—10 years) follow-up will be required using objective tests of valvular competence before the true value of these procedures can be assessed.

Two other papers (Belcaro et al. and Lane et al) report the use of external valvuloplasty in the superficial venous system, notably at the sapheno-femoral junction. It appears from these papers that the restoration of valvular competence at the sapheno-femoral junction results in restoration of valvular competence along the length of the long saphenous vein in the majority of cases. This is in contrast to the procedure of ligation of the sapheno-femoral junction (without long saphenous veins stripping) where previously published data shows that half the long saphenous veins can be identified post-operatively using ultrasound imaging and all are incompetent. Why should there be such a contrast between the two procedures? The protagonists of external banding valvuloplasty suggest that maintenance of flow in the orthograde direction permits normalisation of the flow characteristics and hence of the vein below the junction is restored to normalcy. I believe that the flaw in this argument is that, in many cases, primary incompetence of the long saphenous vein occurs below a competent sapheno-femoral junction. I found this in one third of the patients presenting with primary varicose veins in my own series. Undoubtedly restoration of competence at the sapheno-femoral junction will reduce the severity of reflux in the long saphenous vein, and much improvement in symptoms may be observed as a result of this. I believe that the long term outcome should be studied carefully before this procedure is used widely. One further problem with this approach is a feature previously reported in articles published in this journal. Angioscopic examination of varicose veins often shows partial or complete destruction of valve cusps in the main trunk of the long saphenous vein. It seems improbable that such veins will re-grow normal valves, and will presumably remain incompetent.

The authors of the manuscripts describing these treatments have published their results for examination by the readership of this journal. Clearly these reports are intended as an initial description of the technique and show promising results, but the outcome beyond 5 years is not yet known. Observations and comments (in writing to the Editor) are welcomed in connection with these articles.

It is a pleasure to publish articles which show that the ingenuity of phlebologists to design new treatments for venous disease is not confined to the development of better methods of compression or new drugs. I congratulate the authors on their imagination in a field where major surgical advances have been relatively few.

Design: Three prospective studies were performed. The first study was the subjective and objective evaluation of venous valve cuffing in a series of unselected patients with varicose veins. Indications for use of the technique were defined in the first study, and applied in the second study, which focused on an evaluation of objective outcome criteria. The third study was an evaluation of the long-term effect of venous valve cuffing.

Setting: Royal North Shore Public Hospital, Mater Private Hospital and Peninsula Private Hospital (Sydney, Australia).

Patients: In the first series there were 93 limbs in 72 unselected patients with varicose veins. The second series consisted of 78 limbs in 62 patients who were selected based on the indications established in the first study. A third series of 100 limbs in 75 patients, selected at random, was reviewed to assess the long-term subjective and objective outcome.

Measurements: All clinical outcome variables were observed subjectively. Photoplethysmographic recovery times and reflux at the sapheno-femoral junction (SFJ), at the knee, and below the knee were measured. Vein diameters at the groin and at the knee were measured pre- and postoperatively.

Results: Unselected patients have a good clinical outcome, but approximately one-third have residual venous reflux at the SFJ. Selected patients with mild to moderate varicose veins have an excellent result in all criteria investigated.

Conclusions: After competence is restored to the SFJ, the saphenous vein decreases in size and achieves physiological one-way flow. Venous valve cuffing demonstrates a low incidence of symptoms and recurrence in both the short and long term.

Keywords: External valvuloplasty; Varicose veins; Venocuff; Venous valve cuffing; Venous valve restoration

Design: Patients with venous hypertension resulting from deep and superficial venous incompetence were randomized into two treatment groups.

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

Patients: Both groups were treated with superficial vein surgery. Group 2 was also treated with LAP.

Interventions: Valvuloplasty of the superficial femoral vein was performed with plication of the anterior vein wall after limited dissection of the vein.

Main outcome measures: During a 3-year follow-up results were evaluated with colour duplex and ambulatory venous pressure (AVP) measurements. Endpoints were AVP, refilling time (RT), number of incompetent venous sites, presence/absence of the reflux at the superficial femoral vein and the diameter of the vein.

Results: No complications were observed. All femoral veins treated with LAP were competent at 36 months. Significantly lower AVP and longer RT were observed in the LAP group. The number of incompetent venous sites was lower in both groups. The average diameter of the vein was higher in Group 1.

Conclusions: In selected subjects - moderate deep venous incompetence, functional cusps, incompetence mainly due to relative enlargement of the vein - LAP may be an alternative to external valvuloplasty.

Keywords: Deep venous incompetence; Femoral vein; Plication; Valvuloplasty; Varicose veins; Venous insufficiency; Venous surgery

Design: Retrospective analysis of patients subjected to external banding valvuloplasty (EBV) with the Venocuff in relation to the evolution of venous reflux.

Setting: Department of Vascular Surgery, Instituto Dermopatico dell’Immacolata, Rome, Italy.

Patients: Ten patients with signs and symptoms of chronic venous insufficiency.

Interventions: Application of a Venocuff to the superficial femoral vein.

Main outcome measures: The correction rate of the primary deep venous refiux assessed by venography and colour duplex ultrasound.

Results: In a mean follow-up period of 10 months, deep vein reflux was completely abolished in nine patients (90%).

Conclusions: The Venocuff is an improvement over the previous techniques, of surgical treatment of primary deep venous insufficiency in reducing the dilated valve bulb to the correct size in a quick, standardized and precise way.

Keywords: Chronic venous insufficiency; Deep venous reflux; Deep venous surgery; External banding valvuloplasty; Primary deep venous insufficiency; Venocuff

Design: Prospective study in seven patients with significant perforating vein incompetence in the medial lower leg.

Setting: Department of Surgery, Nepean Hospital, New South Wales, Australia.

Intervention: Laparoscopic equipment is used to explore endoscopically the medial subfascial space of the lower leg. Incompetent perforating veins preoperatively marked by duplex examination are identified and divided by endoscopic diathermy.

Main outcome measures: The endoscopic division close to their source from the deep veins of incompetent perforating veins of the medial compartment of the lower leg.

Results: Endoscopic interruption of incompetent perforators in the medial compartments of seven legs achieved with minimal morbidity.

Conclusions: Endoscopic diathermy interruption of incompetent perforators in the medial compartment of the lower leg using laparoscopic equipment is a rapid and accurate procedure with minimal morbidity, as shown in a small series of seven legs.

Keywords: Endoscopy; Laparoscopic equipment: Perforating veins; Subfascial space; Venous insufficiency

Design: Open, prospective study in patients and healthy, age-matched subjects.

Setting: Department of Angiology, Hannover Medical School.

Patients: Seventy-one patients with chronic venous insufficiency.

Measurements: Transcutaneous oxygen pressure (tcPo₂) at electrode core temperatures of 37°C and 44°C and laser Doppler flux (LDF) were measured simultaneously in different regions of the legs.

Results: On the forefoot, tcPo₂ (37°C) at rest and tcPo₂ (44°C) during arterial ischaemia were significantly higher in patients (P<0.05), increasing with the severity of chronic venous insufficiency.

Conclusions: Cutaneous capillary flow on the forefoot is increased in patients with chronic venous insufficiency, demonstrating the general effect of venous hypertension.

Keywords: Micro-oedema; Vasoconstrictor response; Venous hypertension

Design: Duplex ultrasonography was used to detect superficial and deep venous incompetence. Foot volumetry was used to determine expulsion fraction (expelled volume/total foot volume, EF, %) and half-refilling time (HRT, seconds).

Setting: Hospital outpatients attending the Royal Infirmary of Edinburgh.

Patients: Forty-three patients with venous ulcer disease.

Results: EF, obtained with tourniquet occlusion of superficial veins, in patients without deep vein incompetence was not significantly different from EF in patients with either femoral vein incompetence (FyI), popliteal vein incompetence (PVI) or both. HRT in patients without deep vein incompetence was significantly higher than HRT in patients with FVI (p <0.02), PVI (p <0.01) and both FVI and PVI (p <0.03, Wilcoxon signed rank test). EF and HRT values obtained without tourniquet occlusion were unrelated to the presence or absence of deep vein incompetence. There was no relationship between the results of foot volumetry and superficial vein incompetence.

Conclusions: The results of foot volumetry are related to deep, but not superficial, venous incompetence as demonstrated by duplex ultrasonography.

Keywords: Duplex ultrasound; Foot volumetry; Venous incompetence; Venous ulcer

Design: A descriptive study, reporting six cases, with a discussion of the literature.

Setting: St Thomas’ Hospital Outpatient Department. Patients: Six outpatients.

Conclusions: The development of both squamous carcinoma and basal cell carcinoma may be associated with chronic venous disease of the lower limb. Modest dimensions or a healthy appearance that are out of keeping with a protracted course may be signs of malignancy in a leg ulcer. A punch biopsy under local anaesthesia in the outpatient department provides accurate diagnosis of a malignant ulcer allowing prompt treatment.

Keywords: Basal cell carcinoma; Malignant change; Squamous carcinoma of skin; Venous ulceration

Design: Ankle pulse palpation of patients presenting with ulcerated limbs and comparison with Doppler ankle-brachial pressure index (ABPI).

Patients: Sequential patients presenting to community ulcer clinics.

Main outcome measure: Sensitivity and specificity of pulse palpation to detect arterial disease compared with ABPI.

Results: Of 533 limbs with ulceration in 462 patients (mean age 74 years, 67% female), 167 (31%) had no detectable pulses at the ankle. Of the 93 limbs with ABPI <0.9, 34 (37%) had detectable pulses. Of those limbs with ABPI < 0.9, 108 out of 440 (25%) had no detectable ankle pulses. Sensitivity for lack of pulses as a predictor of arterial disease (ABPI <0.9) was 63% with a specificity of 75% and positive predictive value of only 35%. Using only the absence of palpable pulses would lead to 37% of patients with arterial disease being treated inappropriately.

Conclusion: Palpation of pedal pulses by community nurses is a poor predictor of leg arterial disease and must be used in combination with ABPI. Only when significant arterial disease is excluded should compression be applied.

Keywords: Ankle-brachial pressure index; Arterial disease; Pedal pulses; Ulceration