scholarly journals The hemodynamic impact of the bidirectional flow within calf perforators and conductive veins in varicose vein disease

2020 ◽  
Vol 5 (3) ◽  
Author(s):  
Cestmir Recek ◽  
Keyword(s):  
Saphenous Vein ◽  
Varicose Vein ◽  
Great Saphenous Vein ◽  
Diastolic Pressure ◽  
Venous Pressure ◽  
Lower Leg ◽  
Hemodynamic Assessment ◽  
Pump Activity ◽  
Bidirectional Flow ◽  
Vein Disease

The hemodynamic assessment of the bidirectional flow within calf perforators and in the conductive veins in varicose vein disease is presented. The bidirectional streaming within calf perforators is induced by the changing polarity of the systolic and diastolic pressure gradients arising during calf pump activity between the deep veins and the saphenous system of the lower leg, as documented by simultaneous pressure measurements in the posterior tibial vein and the great saphenous vein. This bidirectional flow makes the deep and superficial veins of the lower leg conjoined vessels. The vector of the bidirectional streaming in varicose vein patients is oriented inward, into the deep veins. The enlarged calf perforators are the consequence of the saphenous reflux; after elimination of saphenous reflux the diameter of calf perforators diminishes significantly. Results of venous pressure, plethysmographic and electromagnetic flow measurements rebut the still prevalent opinion that the outward flow within calf perforators is a reflux. There is an up-and-down flow in the conductive veins during calf pump activity with a prevailing systolic centripetal (orthograde) flow in the popliteal/femoral axis and a diastolic centrifugal (retrograde) flow in the incompetent great saphenous vein. The popliteal vein represents actually the drain pipe of the calf muscle pump. The ambulatory venous pressure gradient arising during the diastolic phase of the calf pump activity resembles the diastolic pressure difference between the aorta and the left ventricle.

Venous pressure gradients in the lower extremity and the hemodynamic consequences

VASA ◽  
2010 ◽  
Vol 39 (4) ◽  
pp. 292-297 ◽  
Author(s):  
Recek
Keyword(s):  
Saphenous Vein ◽  
Pressure Difference ◽  
Great Saphenous Vein ◽  
Varicose Veins ◽  
Femoral Vein ◽  
Venous Pressure ◽  
Lower Leg ◽  
High Ligation ◽  
Venous Reflux ◽  
Pump Activity

Pressure differences play an important role in the hemodynamics of both arterial and venous circulation. Venous ambulatory pressure gradient of about 35 mm Hg arises during the activity of the calf muscle venous pump between the veins in the thigh and the lower leg; this is the initiator launching venous reflux in varicose vein patients. The hemodynamic consequence of venous reflux is interference with the physiological decrease in venous pressure in the lower leg and foot and the occurrence of ambulatory venous hypertension, the degree of which depends on the magnitude of refluxing blood. Pressure difference occurring between the femoral vein and the remnant of great saphenous vein after high ligation or crossectomy during calf pump activity may be the activator of the process leading to the building of new venous communicating channels, the consequence of which is recurrent reflux. Neovascularization is apparently triggered by this hemodynamic factor, not by the surgical procedure itself, because neovascularization does not occur after harvesting of the great saphenous vein in the groin in people without varicose veins. Venous pressure potentials developing in the lower leg during the calf pump activity force the blood to flow from deep into superficial veins during muscle contraction and in the opposite direction during muscle relaxation. An untoward event caused by venous pressure difference is presented - spontaneous bypassing of a competent valve in the saphenous remnant after crossectomy, which converted a favourable hemodynamic situation into a harmful one. Possible explanation of this undesirable event is offered.

Competent and incompetent calf perforators in primary varicose veins: a resistant myth

2016 ◽  
Vol 31 (8) ◽  
pp. 532-540 ◽  
Author(s):  
Cestmir Recek
Keyword(s):  
Saphenous Vein ◽  
Varicose Vein ◽  
Great Saphenous Vein ◽  
Varicose Veins ◽  
Venous Pressure ◽  
Venous Hypertension ◽  
Flow Measurements ◽  
Posterior Tibial ◽  
Primary Varicose Veins ◽  
Bidirectional Flow

The pathophysiology of calf perforators is presented. Bidirectional flow within calf perforators with a prevailing inward, into deep veins oriented component arises during calf pump activity in varicose vein patients, as evidenced by venous pressure measurements, plethysmographic findings, duplex ultrasonography, and electromagnetic flow measurements. Reflux within calf perforators is an inward, not outward, flow; the opinion that the outward flow within calf perforators is a reflux is at odds with the reality. During calf muscle contraction, the pressure in the posterior tibial vein is higher than in the great saphenous vein; it induces the harmless outward flow within calf perforators, which runs further via great saphenous vein in the physiological direction toward the heart. Deep and superficial veins of the lower leg form conjoined vessels, as documented by nearly equal pressure curves registered simultaneously in the posterior tibial and great saphenous veins both in varicose vein patients and in healthy people. Calf perforators do not entail ambulatory venous hypertension or any other hemodynamic disorder, even if enlarged and incompetent; their ligation is needless. The diameter of calf perforators is influenced by the intensity of saphenous reflux; it enlarges with increasing intensity of saphenous reflux and diminishes after the abolition of reflux.

The anatomical relationship between the saphenous nerve and the great saphenous vein

2011 ◽  
Vol 26 (3) ◽  
pp. 114-118 ◽  
Author(s):  
L Veverková ◽  
V Jedlička ◽  
P Vlček ◽  
J Kalač
Keyword(s):  
Radiofrequency Ablation ◽  
Laser Therapy ◽  
Histological Examination ◽  
Saphenous Vein ◽  
Varicose Vein ◽  
Great Saphenous Vein ◽  
Lower Leg ◽  
Saphenous Nerve ◽  
Endovenous Laser Therapy ◽  
Anatomical Relationship

Objective Damage to the saphenous nerve (SN) has been a known complication during varicose vein surgeries. We tested whether a better knowledge of the anatomy of the SN and the great saphenous vein (GSV) can prevent such damage. Methods We conducted a morphological and histological examination on 86 limbs from 43 cadavers in order to analyse the anatomical interrelation between the SN and the GSV in the lower leg and we also measured the distance between the nerve and the vein in a sample of 42 sections from three parts of the lower leg. Results The anatomical relationship between the SN and the GSV is varied and the two structures run close to each other so a better knowledge of their anatomy in itself proved insufficient in preventing damage to the SN. Conclusion However, in the case of endovenous laser therapy and radiofrequency ablation tumescent anaesthesia decreases the risk of damage to the SN.

Significant features characterizing the nature of varicose vein disease

2018 ◽  
Vol 3 (3) ◽  
Author(s):  
Cestmir Recek
Keyword(s):  
Pressure Gradient ◽  
Varicose Vein ◽  
Femoral Vein ◽  
Lower Leg ◽  
Wall Structure ◽  
Venous Reflux ◽  
Vein Wall ◽  
Pump Activity ◽  
Reflux Recurrence ◽  
Vein Disease

The following features characterize varicose vein disease: 1) Venous reflux, 2) Inherent weakness of the vein wall, 3) Tendency to recurrence. Venous reflux is the most important pathological hemodynamic phenomenon causing ambulatory venous hypertension and evoking chronic venous insufficiency; it is released by the ambulatory pressure gradient, which arises during calf pump activity between thigh and lower leg veins. Inherent weakness of the vein wall entails increased vein distensibility. The impaired vein wall structure is not able to resist the dilatation force of the hydrostatic and intra-abdominal pressure; the veins in the lower extremity subsequently dilate, become incompetent, and tend to form varicose veins. Abolition of saphenous reflux removes the hemodynamic disturbance but it simultaneously generates preconditions for reflux recurrence. This run of events is triggered by the drainage of venous blood from the thigh saphenous system into deep lower leg veins, which occurs during calf pump activity. The dividing line of the ambulatory pressure gradient that is located in healthy people just below the knee joint is displaced into the thigh between the femoral vein and the incompetent thigh saphenous system; in this way, pressure gradient between the femoral vein and the incompetent saphenous system occurs and starts the chain of events that evokes reflux recurrence. Hindrance of the untoward drainage at the knee level would prevent generation of this prerequisite for reflux recurrence.

Comparison of Endovasal Laser and Radiofrequency Ablation of Great Saphenous Vein in the Complex Treatment of Lower Limb Varicose Vein Disease

Flebologiia ◽  
2020 ◽  
Vol 14 (2) ◽  
pp. 91
Author(s):  
A.S. Volkov ◽  
M.D. Dibirov ◽  
A.I. Shimanko ◽  
R.U. Gadzhimuradov ◽  
S.V. Tsuranov ◽  
...  
Keyword(s):  
Radiofrequency Ablation ◽  
Saphenous Vein ◽  
Varicose Vein ◽  
Lower Limb ◽  
Great Saphenous Vein ◽  
Complex Treatment ◽  
Vein Disease

Invasive therapeutic options in truncal varicosity of the great saphenous vein

VASA ◽  
2006 ◽  
Vol 35 (3) ◽  
pp. 157-166 ◽  
Author(s):  
Hach-Wunderle ◽  
Hach
Keyword(s):  
Minimally Invasive ◽  
Saphenous Vein ◽  
Venous Insufficiency ◽  
Great Saphenous Vein ◽  
Varicose Veins ◽  
Venous Pressure ◽  
Stage Iii ◽  
High Ligation ◽  
Surgical Trauma ◽  
Disease Stages

It is known from current pathophysiology that disease stages I and II of truncal varicosity of the great saphenous vein do not cause changes in venous pressure on dynamic phlebodynamometry. This is possibly also the case for mild cases of the disease in stage III. In pronounced cases of stage III and all cases of stage IV, however, venous hypertension occurs which triggers the symptoms of secondary deep venous insufficiency and all the complications of chronic venous insufficiency. From these facts the therapeutic consequence is inferred that in stages I and II and perhaps also in very mild cases of stage III disease, it is enough "merely" to remove varicose veins without expecting there to be any other serious complications in the patient’s further life caused by the varicosity. Recurrence rates are not included in this analysis. In marked cases of disease stages III and IV of the great saphenous vein, however, secondary deep venous insufficiency is to be expected sooner or later. The classical operation with saphenofemoral high ligation ("crossectomy") and stripping strictly adheres to the recognized pathophysiologic principles. It also takes into account in the greatest detail aspects of minimally invasive surgery and esthetics. In the past few years, developments have been advanced to further minimize surgical trauma and to replace the stripping maneuver using occlusion of the trunk vein which is left in place. Obliteration of the vessel is subsequently performed via transmission of energy through an inserted catheter. This includes the techniques of radiofrequency ablation and endovenous laser treatment. High ligation is not performed as a matter of principle. In a similar way, sclerotherapy using microfoam is minimally invasive in character. All these procedures may be indicated for disease stages I and II, and with reservations also in mild forms of stage III disease. Perhaps high ligation previously constituted overtreatment in some cases. Targeted studies are still needed to prove whether secondary deep venous insufficiency can be avoided in advanced stages of varicose vein disease without high ligation and thus without exclusion of the whole recirculation circuit.

Evidence that venous hypertension causes stasis dermatitis

2011 ◽  
Vol 26 (8) ◽  
pp. 361-365 ◽  
Author(s):  
K Sippel ◽  
D Mayer ◽  
B Ballmer ◽  
G Dragieva ◽  
S Läuchli ◽  
...  
Keyword(s):  
Saphenous Vein ◽  
Great Saphenous Vein ◽  
Lower Leg ◽  
Venous Hypertension ◽  
Consecutive Series ◽  
Contact Sensitization ◽  
Clinical Model ◽  
Long Saphenous Vein ◽  
Nickel Cobalt

A clinical model to examine the hypothesis that venous hypertension of the lower leg per se can cause lower leg stasis dermatitis is described. To prove this concept, we retrospectively studied a consecutive series of 38 patients with lower leg dermatitis who underwent phlebological examination at our consultation over a period of four years. Among those patients who had an insufficiency of the superficial veins only, without insufficiency of the deep veins, 22 had undergone patch testing to common allergens in phlebology. We found 10 patients with a stasis dermatitis of the lower leg and an incompetent great saphenous vein, six of whom had no detectable contact sensitization at all and another four exclusively to phlebologically irrelevant substances, e.g. nickel, cobalt, chromate or epoxid resin. All these 10 patients showed long saphenous vein incompetence from the groin to the medial aspect of the leg. All were operated by classical flush ligation and saphenectomy. Lower leg dermatitis healed in all 10 patients within 8–12 weeks and no recurrence was observed (1 year follow-up). These results support clinical experience that venous hypertension alone indeed can cause lower leg dermatitis.

Varicose Vein Surgery

2011 ◽  
Author(s):  
Jovan N. Markovic ◽  
Cynthia K. Shortell
Keyword(s):  
Laser Ablation ◽  
Saphenous Vein ◽  
Varicose Vein ◽  
Great Saphenous Vein ◽  
Significant Proportion ◽  
The United States ◽  
Clinical Severity ◽  
Treatment Modalities ◽  
Venous Disease ◽  
Varicose Vein Surgery

Chronic venous insufficiency (CVI) is a common vascular disorder that affects a significant proportion of the population in the United States and other developed countries. In its advanced stages, CVI significantly reduces patients’ quality of life and imposes a high economic burden on society due to increased direct health care costs and reduced productivity. Favorable clinical results associated with endovascular ablation techniques and patient preference for minimally invasive procedures has led to a shift in which treatment of vein disease is moving from the hospital to the office, allowing a more diverse group of physicians to enter a field that had typically been the domain of surgeons. This chapter reviews the terminology associated with venous disease, indications for varicose vein surgery, preoperative evaluation, procedural planning, endovenous procedures (endovenous laser ablation, radiofrequency ablation), surgical vein stripping techniques, and foam sclerotherapy. Tables include Clinical severity, Etiology or Cause, Anatomy, Pathophysiology classification; summary of nomenclature changes for the lower extremity venous system; indications for varicose vein surgery; interrogation points in the venous reflux examination; complications associated with treatment modalities used in the management of CVI; and methods of variceal ablation. Figures show an ultrasonographic image of a saphenous eye, placement of a quartz fiber for laser ablation of the great saphenous vein, a typical saphenofemoral junction, surgical stripping  of the great saphenous vein, and microfoam sclerotherapy. This review contains 9 figures, 6 tables and 73 references.

Inferior selective crossectomy for great saphenous vein incompetence: Our experience

Vascular ◽  
2020 ◽  
pp. 170853812094725
Author(s):  
Maurizio Pagano ◽  
Giovanna Passaro ◽  
Roberto Flore ◽  
Paolo Tondi
Keyword(s):  
Saphenous Vein ◽  
Varicose Vein ◽  
Great Saphenous Vein ◽  
Duplex Ultrasound ◽  
Venous Disease ◽  
Recurrence Rates ◽  
Saphenofemoral Junction

Objective To describe the mid-term outcome after inferior selective crossectomy in a subset of patients with symptomatic chronic venous disease and both great saphenous vein and suprasaphenic valve incompetence. Methodsː Retrospective analysis of prospectively collected data was conducted. During an eight-year period, 1095 ligations of all saphenofemoral junction inferior tributaries and great saphenous vein stripping were performed in 814 Clinical, Etiology, Anatomy, Pathophysiology C2–C6 patients. Duplex ultrasound follow-up examinations were performed after 30 days, 6 months, and 2 years, and saphenofemoral junction hemodynamic patterns and varicose veins recurrence rates were evaluated. Results Two hundred and twenty patients completed the two-year follow-up period. At the 30-day Duplex ultrasound evaluations, two different hemodynamic patterns were described. Type 1, with physiological drainage of saphenofemoral junction superior tributaries, was observed in 214 patients. Type 2, without flow in saphenofemoral junction superior tributaries, was observed in six patients. Overall varicose vein recurrence rates were 0, 2.3, and 2.7% at the 30-day, 6-month, and 2-year follow-up examinations, respectively. At the two-year follow-up, Type 1 patients showed 0% varicose vein recurrence, while Type 2 patients showed 100%. Conclusionsː Inferior selective crossectomy seems to be a valid and safe option in case of both suprasaphenic valve and great saphenous vein incompetence. Duplex ultrasound evaluation, according to our protocol, allows us to identify two different saphenofemoral junction hemodynamic patterns that could predict varicose vein recurrence at mid-term. An optimal stump washing after inferior selective crossectomy, warranted by patency and large caliber saphenofemoral junction superior tributaries, seems to be the key point in preventing varicose vein recurrence in this context. However, large prospective studies regarding saphenofemoral junction modifications and varicose vein recurrence are needed to confirm these preliminary observations.

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