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

The Vein Book ◽

10.1016/b978-012369515-4/50060-0 ◽

2007 ◽

pp. 529-534

Author(s):

FEDOR LURIE ◽

ALESSANDRA PUGGIONI ◽

ROBERT L. KISTNER

Keyword(s):

Chronic Venous Insufficiency ◽

Venous Insufficiency ◽

Ultrasound Guided ◽

Perforating Veins

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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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