Ultrasound-Guided Sclerotherapy (USGS) of Perforating Veins in Chronic Venous Insufficiency

Objective: To review the techniques and results of surgical treatment of the superficial and perforating veins in patients with chronic venous insufficiency. Methods: The current techniques used at the Mayo Clinic for treatment of simple varicose veins and venous ulcers are presented. Results of subfascial endoscopic perforator vein surgery (SEPS) are discussed and data from large centres are tabulated. Results are compared with those reported following non-operative management. Synthesis: High ligation and invagination stripping of the incompetent segment of the saphenous vein, with stab avulsion of branch varicosities, is the optimal surgical technique to ablate superficial venous incompetence. SEPS is safer than open perforator vein ligation and is the technique of choice to interrupt incompetent perforating veins. A review of 12 series on SEPS, that included 361 limbs, found an ulcer recurrence rate of 10% in those 211 patients who underwent ablation of superficial reflux together with SEPS. One hundred and fifty limbs had SEPS alone, without saphenous stripping: ulcer recurrence in this group at a mean of 23 months was 12%. Results in primary valvular incompetence were significantly better than in post-thrombotic syndrome. Conclusions: Ablation of superficial reflux remains the main surgical treatment of all forms of chronic venous insufficiency. SEPS is safe and effective to interrupt medial calf perforators and results in rapid ulcer healing and low recurrence in patients with primary valvular incompetence. The treatment of post-thrombotic syndrome remains a challenge. Results of the North American Venous Ulcer Surgery (NAVUS) trial, a prospective, randomised, multicentre study, will be required to provide level 1 evidence of the effectiveness of surgical treatment over medical therapy in the treatment of venous ulcers.

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Chronic Venous Insufficiency and the Therapeutic Effects of Daflon 500 mg

Angiology ◽

10.1177/00033197050560i104 ◽

2005 ◽

Vol 56 (6_suppl) ◽

pp. S21-S24 ◽

Cited By ~ 17

Author(s):

John J. Bergan

Keyword(s):

Shear Stress ◽

Chronic Venous Insufficiency ◽

Venous Insufficiency ◽

Venous Pressure ◽

Vena Cava ◽

Venous Hypertension ◽

Therapeutic Effects ◽

Inflammatory Cascade ◽

Perforating Veins ◽

Days Of Therapy

Chronic venous insufficiency is linked to venous hypertension and forces of shear stress on the endothelium. Venous hypertension depends upon two forces: the weight of a column of blood from the right atrium transmitted through the valveless vena cava and iliac veins to the femoral vein, and pressure generated by contracting skeletal muscles of the leg transmitted through failed perforating veins. When valve failure occurs in superficial axial veins and perforating veins, the venous pressure in the veins and venules of the skin and subcutaneous tissue is raised. The skin changes in chronic venous insufficiency are directly related to the severity of the venous hypertension. Also, pathologic changes in the valves are linked to venous hypertension and leukocyte infiltration and activation. It is hypothesized that acute venous pressure elevations cause a shift in the venous hemodynamics with changes in wall shear stress. This initiates the inflammatory cascade. Daflon 500 mg ameliorates the effects of chronic inflammation. In randomized trials, 60 days of therapy with Daflon at a dosage of 500 mg 2 tablets daily was effective, in addition to elastic compression, in accelerating venous ulcer healing. Because venous insufficiency is linked to venous hypertension and an inflammatory reaction, it appears that Daflon 500 mg 2 tablets daily shows a great potential for accomplishing blockade of the inflammatory cascade.

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A Reassessment of the Role of Perforating Veins in Chronic Venous Insufficiency

Phlebology The Journal of Venous Disease ◽

10.1177/026835559000500204 ◽

1990 ◽

Vol 5 (2) ◽

pp. 85-94 ◽

Cited By ~ 4

Author(s):

G.M. McMullin ◽

H.J. Scott ◽

P.D. Coleridge Smith ◽

J.H. Scurr

Keyword(s):

Chronic Venous Insufficiency ◽

Venous Insufficiency ◽

Clinical Symptoms ◽

Reverse Flow ◽

Venous Pressure ◽

Signs And Symptoms ◽

Venous Hypertension ◽

Venous Disease ◽

Perforating Veins ◽

Clinically Normal

Ambulatory venous hypertension is closely associated with the signs and symptoms of venous disease. It has been shown that reverse flow of blood in the superficial and deep veins is responsible. The pressure derangement caused by incompetence of perforating veins has not been established. The present study documents the pressure disturbances caused by incompetence in each of the three compartments of the venous system, the deep, the superficial and the perforating veins. In total 90 limbs of 49 patients with chronic venous insufficiency were examined and classified by duplex scanning and ascending venography. Ambulatory venous pressure measurements were performed on all 90 limbs and a venous sufficiency index (VSI) for each limb calculated from the percentage drop in pressure and refilling time. VSI was lowest in the group with deep vein incompetence (median 0.9, range 0–36.9), intermediate in the groups with superficial vein incompetence (median 7.6, range 0.4–59) and with incompetent perforating veins (median 14.6, range 0.4–35.7) and highest in the group with normal veins (median 41.7, range 3.5–87.5). The association of symptoms and VSI was also examined. The lower the VSI the more severe were the clinical symptoms and all ulcerated limbs had a VSI < 20. However a number of clinically normal limbs were also found to have low values of VSI.

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Prevalence and distribution of incompetent perforating veins in chronic venous insufficiency

Journal of Vascular Surgery ◽

10.1016/s0741-5214(98)70056-4 ◽

1998 ◽

Vol 28 (5) ◽

pp. 815-825 ◽

Cited By ~ 47

Author(s):

Konstantinos T. Delis ◽

Veronica Ibegbuna ◽

Andrew N. Nicolaides ◽

Augusto Lauro ◽

Hani Hafez

Keyword(s):

Chronic Venous Insufficiency ◽

Venous Insufficiency ◽

Perforating Veins

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Treatment of severe chronic venous insufficiency with ultrasound-guided foam sclerotherapy: A two-year series in a single center in Brazil

Phlebology The Journal of Venous Disease ◽

10.1177/0268355513517225 ◽

2013 ◽

Vol 30 (2) ◽

pp. 113-118 ◽

Cited By ~ 12

Author(s):

F Coelho Neto ◽

GR de Araújo ◽

I Moraes Kessler ◽

R Fernandes Batista de Amorim ◽

D Pinheiro Falcão

Keyword(s):

Ulcer Healing ◽

Chronic Venous Insufficiency ◽

Venous Insufficiency ◽

Low Cost ◽

Federal District ◽

P Value ◽

Ultrasound Guided ◽

Foam Sclerotherapy ◽

Advanced Stages ◽

Level Of Significance

Objectives To portray the initial experience at a public health center of the Federal District of Brazil in the treatment of chronic venous insufficiency with ultrasound-guided foam sclerotherapy in patients in advanced stages of the disease. Method Eighty-seven reports of patients in C5 and C6 stages, according to CEAP classification, were evaluated for clinical improvements, ulcer-healing rates, and complications of ultrasound-guided foam sclerotherapy. McNemar test was used for statistical analysis with the level of significance set at 5% ( P-value, 0.05). Results The results showed high rates of ulcer healing (85%) and significant improvement of symptoms after treatment, such as pain, heaviness, fatigue, burning, paresthesia, and itching ( P < 0.0001). Conclusions An outpatient, low-cost and high-resolution technique, without the need for hospitalization and use of the operating room showed to be a safe and effective alternative for the treatment of varicose disease associated with severe chronic venous insufficiency.

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Endoscopic anatomy of perforating veins in chronic venous insufficiency of the legs: “Solitary” incompetent perforating veins are often actually multiple vessels

International Journal of Angiology ◽

10.1007/s00547-004-1045-3 ◽

2011 ◽

Vol 13 (01) ◽

pp. 31-36 ◽

Cited By ~ 1

Author(s):

Naoki Haruta ◽

Ryo Shinhara ◽

Keizo Sugino ◽

Yasutomo Ojima ◽

Masatugu Yano ◽

...

Keyword(s):

Chronic Venous Insufficiency ◽

Venous Insufficiency ◽

Endoscopic Anatomy ◽

Perforating Veins

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Ultrasound-guided foam sclerotherapy for severe chronic venous insufficiency

Revista do Colégio Brasileiro de Cirurgiões ◽

10.1590/0100-69912017005014 ◽

2017 ◽

Vol 44 (5) ◽

pp. 511-520 ◽

Cited By ~ 3

Author(s):

Guilherme Camargo Gonçalves de-Abreu ◽

Otacílio de Camargo Júnior ◽

Márcia Fayad Marcondes de-Abreu ◽

José Luís Braga de-Aquino

Keyword(s):

Minimally Invasive ◽

Lower Limb ◽

Chronic Venous Insufficiency ◽

Thermal Ablation ◽

Venous Insufficiency ◽

Varicose Veins ◽

Venous Hypertension ◽

Ultrasound Guided ◽

Foam Sclerotherapy ◽

New Techniques

ABSTRACT Chronic venous insufficiency is characterized by cutaneous alterations caused by venous hypertension; in severe forms, it progresses to lower limb ulcers. Lower limb varicose veins are the main cause of chronic venous insufficiency, and the classic treatment includes surgery and compressive therapy. Minimally invasive alternative treatments for varicose veins include new techniques such as venous thermal ablation using laser or radiofrequency. The use of different methods depends on clinical and anatomical factors. Ultrasound-guided foam sclerotherapy is the venous injection of sclerosing foam controlled by Doppler ultrasound. Sclerotherapy is very useful to treat varicose veins, and probably, is cheaper than other methods. However, until the present, it is the less studied method.

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