Direct Venous Surgery for Venous Valvular Insufficiency of the Lower Extremity

Usually, venous insufficiency affecting an extremity results from elevated pressure, whereas arterial insufficiency usually is caused by reduced pressure energy. Except when caused by arteriovenous fistulae, elevated venous pressures are caused by obstruction to outflow and/or by incompetence of the venous valves, particularly at popliteal level and in the calf perforator veins. In the lower extremity, such elevated venous pressures can result in chronic changes that cause symptoms and/or signs that range from “tired legs” to ulceration. Although mild venous hypertension may constitute only a relative inconvenience such as varicose veins, more severe cases can lead to debilitating ulceration that may demand a change in lifestyle. Assessing an extremity for venous valvular insufficiency means detecting venous reflux. This work describes the plethysmographic, continuous-wave Doppler, and duplex ultrasound imaging modalities that can be used for detecting venous reflux in the deep, superficial, and perforating veins. Although plethysmographic and continuous-wave Doppler modalities have been supplanted largely by duplex ultrasound imaging, they have been included for completeness because they can continue to fulfill a role in overall functional assessment. Whatever the testing modality used to assess venous reflux, it is essential to verify the patency of the deep veins before any intervention in the superficial venous system.

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Prevalence and management of ovarian venous insufficiency in the presence of leg venous insufficiency

Phlebology The Journal of Venous Disease ◽

10.1258/026835507779700617 ◽

2007 ◽

Vol 22 (1) ◽

pp. 29-33 ◽

Cited By ~ 6

Author(s):

R Sutaria ◽

A Subramanian ◽

B Burns ◽

H Hafez

Keyword(s):

Lower Extremity ◽

Lower Limb ◽

Venous Insufficiency ◽

Varicose Veins ◽

Vena Cava ◽

Vascular Surgeon ◽

Venous Surgery ◽

Magnetic Resonance Imaging Mri ◽

The Right ◽

Superficial Venous Insufficiency

Objective: The correlation between ovarian venous insufficiency and lower limb venous insufficiency remains poorly understood. Clinically, incompetent ovarian veins in association with lower extremity varicose veins are suspected when leg varicose veins are found in atypical distributions. Such distributions include upper lateral or posterior thigh, on the buttocks, crossing the inguinal ligament, and also in the vulval or perineal regions. The aim of this study was to determine the prevalence of ovarian venous insufficiency in those with clinically suspicious varicose veins, and to assess the effectiveness of ovarian venous embolization/ligation in treating this condition. Methods: Between June 2001 and December 2004, 424 female patients with lower limb superficial venous insufficiency were seen by a single vascular surgeon. These patients were clinically assessed, and those with atypical varicose veins were investigated with venous duplex examination and magnetic resonance imaging (MRI) venography. Patients with proven ovarian venous insufficiency were offered venography with a view to embolization or laparoscopic ligation. Results: A total of seven patients were clinically suspected of having ovarian venous insufficiency, of which three had recurrent varicose veins (42.9%). Of these, six were confirmed on MRI venography with the left side being more affected than the right; one of them had an occluded vena cava, three were treated by embolization, and two had laparoscopic ligation. Discussion: The prevalence of clinically detectable ovarian venous insufficiency in association with lower extremity varicose veins is in the region of 1.65%. Compared with the estimated prevalence of incidental ovarian venous insufficiency of 10–47%, this suggests that only a minority of incompetent ovarian veins will present with clinically detectable lower limb venous insufficiency. In our opinion, patients with signs suggestive of ovarian venous insufficiency in association with lower limb venous insufficiency should have their ovarian insufficiency controlled prior to embarking on limb venous surgery.

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Combining Values

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2002.marapr01 ◽

2002 ◽

Vol 7 (2) ◽

pp. 1-4, 12 ◽

Cited By ~ 1

Author(s):

Christopher R. Brigham

Keyword(s):

Lower Extremity ◽

Upper Extremity ◽

Evaluation Method ◽

Proximal Phalanx ◽

Common Error ◽

The Third ◽

Whole Person ◽

Impairment Ratings ◽

Upper Extremity Impairment ◽

The Individual

Abstract To account for the effects of multiple impairments, evaluating physicians must provide a summary value that combines multiple impairments so the whole person impairment is equal to or less than the sum of all the individual impairment values. A common error is to add values that should be combined and typically results in an inflated rating. The Combined Values Chart in the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, includes instructions that guide physicians about combining impairment ratings. For example, impairment values within a region generally are combined and converted to a whole person permanent impairment before combination with the results from other regions (exceptions include certain impairments of the spine and extremities). When they combine three or more values, physicians should select and combine the two lowest values; this value is combined with the third value to yield the total value. Upper extremity impairment ratings are combined based on the principle that a second and each succeeding impairment applies not to the whole unit (eg, whole finger) but only to the part that remains (eg, proximal phalanx). Physicians who combine lower extremity impairments usually use only one evaluation method, but, if more than one method is used, the physician should use the Combined Values Chart.

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Quick Reference: Chapter 3: The Musculoskeletal System and Chapter 4: The Nervous System

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2000.mayjun03 ◽

2000 ◽

Vol 5 (3) ◽

pp. 4-4

Keyword(s):

Nervous System ◽

Lower Extremity ◽

Musculoskeletal System ◽

Multistep Method ◽

Manual Muscle Testing ◽

Motor Deficits ◽

Lower Extremity Weakness ◽

Residual Symptoms ◽

Muscle Testing ◽

Almost All

Abstract Lesions of the peripheral nervous system (PNS), whether due to injury or illness, commonly result in residual symptoms and signs and, hence, permanent impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, divides PNS deficits into sensory and motor and includes pain in the former. This article, which regards rating sensory and motor deficits of the lower extremities, is continued from the March/April 2000 issue of The Guides Newsletter. Procedures for rating extremity neural deficits are described in Chapter 3, The Musculoskeletal System, section 3.1k for the upper extremity and sections 3.2k and 3.2l for the lower limb. Sensory deficits and dysesthesia are both disorders of sensation, but the former can be interpreted to mean diminished or absent sensation (hypesthesia or anesthesia) Dysesthesia implies abnormal sensation in the absence of a stimulus or unpleasant sensation elicited by normal touch. Sections 3.2k and 3.2d indicate that almost all partial motor loss in the lower extremity can be rated using Table 39. In addition, Section 4.4b and Table 21 indicate the multistep method used for spinal and some additional nerves and be used alternatively to rate lower extremity weakness in general. Partial motor loss in the lower extremity is rated by manual muscle testing, which is described in the AMA Guides in Section 3.2d.

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Q&A: Multiple Lower Extremity Impairments and AMA Guides, Third Edition, Revised

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2017.marapr05 ◽

2017 ◽

Vol 22 (2) ◽

pp. 15-16

Author(s):

Christopher R. Brigham ◽

Kathryn Mueller ◽

Steven Demeter ◽

Randolph Soo Hoo

Keyword(s):

Lower Extremity

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Spinal Impairment Evaluation: Fifth Edition Changes

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2001.janfeb01 ◽

2001 ◽

Vol 6 (1) ◽

pp. 1-3

Author(s):

Robert H. Haralson

Keyword(s):

Spinal Cord ◽

Lower Extremity ◽

Range Of Motion ◽

Upper Extremity ◽

Spinal Cord Injuries ◽

Clinical Findings ◽

Fourth Edition ◽

Treatment Results ◽

Standard Terminology ◽

Made In

Abstract The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, was published in November 2000 and contains major changes from its predecessor. In the Fourth Edition, all musculoskeletal evaluation and rating was described in a single chapter. In the Fifth Edition, this information has been divided into three separate chapters: Upper Extremity (13), Lower Extremity (14), and Spine (15). This article discusses changes in the spine chapter. The Models for rating spinal impairment now are called Methods. The AMA Guides, Fifth Edition, has reverted to standard terminology for spinal regions in the Diagnosis-related estimates (DRE) Method, and both it and the Range of Motion (ROM) Method now reference cervical, thoracic, and lumbar. Also, the language requiring the use of the DRE, rather than the ROM Method has been strengthened. The biggest change in the DRE Method is that evaluation should include the treatment results. Unfortunately, the Fourth Edition's philosophy regarding when and how to rate impairment using the DRE Model led to a number of problems, including the same rating of all patients with radiculopathy despite some true differences in outcomes. The term differentiator was abandoned and replaced with clinical findings. Significant changes were made in evaluation of patients with spinal cord injuries, and evaluators should become familiar with these and other changes in the Fifth Edition.

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