Postthrombotic or non-postthrombotic severe venous insufficiency: impact of removal of superficial venous reflux with or without subcutaneous fasciotomy.

BACKGROUND: Severe chronic venous insufficiency is often associated with therapy-resistant or recurrent venous leg ulcers, either as a result of deep vein thrombosis (DVT)- (postthrombotic syndrome [PTS]) or superficial venous insufficiency (SVI). Frequently present dermatoliposclerosis affects the skin as well as the subcutaneous and subfascial structures, which may impact tissue pressures and compromise skin perfusion. This study was undertaken to measure tissue pressures in PTS and SVI limbs and to evaluate the impact of removal of superficial venous reflux with or without concomitant subcutaneous fasciotomy. MATERIAL: In eight patients with recurrent, therapy-resistant venous leg ulcers, due to PTS (11 limbs, 12 ulcers) and 14 patients with severe SVI (14 limbs, 14 ulcers), subcutaneous fasciotomy was performed in addition to removal of superficial reflux. They were compared with eight patients with PTS (11 limbs, 11 ulcers) and 10 patients with SVI (13 limbs, 13 ulcers) who did not have fasciotomy in addition to removal of their superficial venous reflux. Intramuscular (i.m.) and subcutaneous (s.c.) tissue pressures and transcutaneous oxygen tension (TcPO(2)) were measured prior to, immediately after, and 3 months following the surgical intervention. Healing of ulcer (spontaneous or by skin grafting) at 3 months was also observed. RESULTS: There were no statistical differences between the groups regarding gender and age distribution or ulcer age at the time of surgery. All patients had in addition to surgery compression stockings class II (30 mm Hg). The i.m. tissue pressure was higher in patients with PTS compared with SVI patients, while s.c. tissue pressure and TcPO(2) did not differ between the groups. When fasciotomy was performed, i.m. and s.c. tissue pressures decreased and TcPO(2) increased significantly. Without fasciotomy, only s.c. tissue pressure decreased first at 3 months postoperatively. In the SVI-group, i.m tissue pressure was significantly decreased at 3 months in the group without fasciotomy. CONCLUSIONS: Patients with severe chronic venous insufficiency with therapy-resistant or recurrent ulcer disease due to deep and superficial insufficiency have higher i.m. tissue pressures than patients with only superficial venous reflux, even though both groups have higher i.m. and s.c. tissue pressures compared with normal values. Eradication of all superficial reflux lowers s.c. tissue pressure, while additional fasciotomy lowers both i.m. and s.c. tissue pressures and increases TcPO(2), which seems to promote ulcer healing.

Molecular characterization of post-thrombotic syndrome.

The post-thrombotic syndrome represents a poorly understood and significant vascular health problem. This review focuses on our current understanding of the pathogenesis of post-thrombotic syndrome. We emphasize the cellular and molecular mechanisms that are responsible for the critical components of post-thrombotic syndrome. These include the initiation of deep venous thrombosis, the pathogenesis of elevated venous pressure, and the factors responsible for nonhealing of venous stasis ulcers.

Effect of chronic wound exudates and MMP-2/-9 inhibitor on angiogenesis in vitro.

BACKGROUND: New evidence suggests that matrix metalloproteinases (MMPs) may facilitate angiogenesis as well as function to generate angiogenesis inhibitors. In this study, the angiogenic effect of wound exudates from patients with venous insufficiency ulcers was examined in an in vitro angiogenesis model with and without synthetic MMP-2/-9 inhibitor. METHODS: Wound exudates were obtained from 20 patients with venous insufficiency ulcers and 20 control patients with donor-site wounds after skin grafting for burns. In the angiogenesis model, suramin (20 microg/ml) was used in five wells without wound fluid as negative control, and vascular endothelial growth factor (1 microg/ml) was used in five other wells as positive control. Chronic wound fluids were analyzed without and with a synthetic MMP-2/-9 inhibitor with a concentration of 2 microM and 20 microM in the medium. The total length of tubules was calculated by map reader. Statistical analysis was performed using the Mann-Whitney test. The level of significance was considered to be p < 0.05. RESULTS: Chronic ulcer exudates inhibited angiogenesis significantly (490 +/- 130 microm) compared with acute wound fluids (1740 +/- 320 microm; p < 0.05). In wells with chronic wound exudates and high concentrations of MMP-2/-9 inhibitor, angiogenesis was stimulated significantly (870 +/- 220 microm, p < 0.05). CONCLUSIONS: In this model, reduced angiogenesis might be due to an antiangiogenic effect of MMP-2 and MMP-9. MMP-2/-9 inhibition results in a stimulation of angiogenesis and might be an approach for the treatment of patients with chronic wounds and reduced angiogenesis.

Origin and natural history of deep vein thrombosis of the legs.

Deep vein thrombosis (DVT) is a disorder frequently affecting the deep veins of the lower limbs; its onset is induced by known risk factors. The main complications of DVT are pulmonary embolism and postthrombotic syndrome (PST). Clinical pulmonary embolism occurs in a high proportion of cases of untreated proximal DVT and is associated with a mortality rate of 11-23% if not treated. PST, however, is a cause of increased morbidity and disability. The natural history of DVT is a dynamic process, with both thrombolysis and thrombus extension occurring after an episode of DVT. With the introduction of duplex scanning, several clinical studies have investigated and tried to clarify the natural history of DVT, the rate of recanalization of the thrombus, and the presence of reflux and its relation to lysis of the thrombus. These and other debated issues associated with PST are reviewed here. Knowledge of the evolution of these processes could result in better understanding of PST and be applied for improvement of medical and surgical management of venous thrombosis and its complications.

Postthrombotic syndrome after isolated calf deep venous thrombosis: the role of popliteal reflux.

OBJECTIVE: The purpose of this study was to evaluate the long-term clinical and hemodynamic outcomes after isolated first-time calf deep venous thrombosis (cDVT). METHODS: This retrospective clinical study was set in an academic referral center. From 1990 to 1994, 617 patients were seen with acute DVT. This number included 82 patients with phlebographically confirmed cDVT. Of those patients, 50 attended the clinical assessment 6 to 10 years (mean, 8.4 years) after the acute event. All patients with cDVT underwent treatment with anticoagulant therapy (96% heparin and warfarin, 4% only warfarin). The duration of the heparin treatment was 4.0 to 8.0 days (mean, 6.4 days), and warfarin was given for 2.0 to 7.5 months (mean, 3.4 months). Compression stockings were used regularly (mean, 9.2 months; range, 0.25 to 64 months) in 30% of the patients after acute cDVT. The initial ipsilateral phlebograms were reevaluated to confirm the diagnosis of cDVT without popliteal involvement. The clinical assessment included evaluation of both legs according to CEAP clinical classification C0-6. Bilateral color-flow duplex scan imaging was performed to assess reflux in deep popliteal segments. Photoplethysmographic measurement of venous refilling time was conducted in both legs to observe deep reflux. RESULTS: The mean age was 57 years (range, 30 to 76 years) at the time of the clinical assessment. Cause of acute cDVT was idiopathy in 52%, coagulopathy in 2%, trauma in 10%, immobilization in 22%, and postoperative in 14% of the cases. During the follow-up period, seven recurrent DVTs (14%) were seen. In the clinical assessment, 17 legs (34%) with previous cDVT had skin changes (CEAP C4-6). No active ulcers were found. Contralaterally, the frequency of C4-6 was 10% (n = 5; P <.05). After exclusion of recurrent DVTs, the distribution of the clinical classification still remained the same. Deep popliteal reflux was detected in 20 legs (40%) with previous cDVT. Contralaterally, popliteal reflux was seen in nine cases (18%; P <.05). Plethysmography showed deep reflux in 16 legs (33%) with cDVT and in nine cases (18%) contralaterally (P >.05). A significant association was found between deep popliteal reflux and skin changes (P <.05). CONCLUSION: In the long-term follow-up, cDVT may lead to significant postthrombotic disease. Reflux in the primarily uninvolved popliteal vein is frequent and may be associated with more severe disease.

The development of postthrombotic syndrome in relationship to venous reflux and calf muscle pump dysfunction at 2 years after the onset of deep venous thrombosis.

OBJECTIVE: Postthrombotic syndrome (PTS) develops in 40% to 60% of patients with deep venous thrombosis. Factors that are important in the development of PTS include venous reflux, deep vein obstruction, and calf muscle pump dysfunction (CMD). METHODS: Reflux and CMD in relationship to the severity of PTS were evaluated in a 2-year follow-up study of patients with acute deep venous thrombosis. Duplex scanning was used to measure reflux. The supine venous pump function test (SVPT) measures CMD with strain-gauge plethysmography. The base-line examination was performed within 1 to 5 days after diagnosis. The next examinations were scheduled at 3, 6, 12, and 24 months. RESULTS: The study included 86 legs, and the 2-year follow-up period was completed for 70 legs. Significantly more reflux was found in previously thrombosed vein segments, with an odds ratio of 1.8 after 3 months, of 2.1 after 6 months, of 2.5 after 12 months, and of 3.2 after 24 months. Multiple regression results showed that the most important risk factor for early clinical signs of PTS was superficial reflux in months 3, 6, and 12 (P < or =.02). Deep reflux did not have a synergistic relationship with superficial reflux in correlation with the clinical signs of PTS. The SVPT was not able to predict the development of PTS. CONCLUSION: More reflux develops in previously thrombosed vein segments. As early as after the third month, patients with superficial reflux have an increased risk of development of the first clinical signs of PTS. Within 2 years, the SVPT shows no relationship with clinical signs of PTS.

Improved hemodynamic effectiveness and associated clinical correlations of a new intermittent pneumatic compression system in patients with chronic venous insufficiency.

PURPOSE: A new intermittent pneumatic compression device (SCD Response System) has recently been shown in healthy volunteers to have the ability to detect the postcompression refilling of the calf veins and to respond by initiating the subsequent cycle when these veins are full. This has proven to be more effective in expelling blood proximally than the conventional intermittent pneumatic compression device (SCD Sequel System). The aim of this study was to test the influence of venous disease on the postcompression refill time detected by means of the SCD Response and the effectiveness of the new system in expelling blood in patients who have venous reflux caused by post-thrombotic syndrome or varicose veins. METHODS: This open, controlled trial was conducted in an academic vascular unit with 10 patients who had post-thrombotic syndrome and 10 patients who had varicose veins. The new SCD Response System was tested against the existing SCD Sequel System in both legs in the supine, semirecumbent, and sitting positions. The refilling time sensed by means of the device was correlated with the venous filling index by using air plethysmography. The total volume of blood expelled per hour during compression was compared with that expelled by the SCD Sequel System in the same volunteers and in the same positions. RESULTS: An inverse association was found between the mean postcompression refilling time in the sitting position and the venous filling index of the apparently healthy or less severely affected leg (r = -0.52, P =.019), the refill time being significantly shorter in patients with advanced venous disease. The SCD Response System increased the volume expelled per hour in the post-thrombotic leg, when compared with the SCD Sequel System, by 109.9% (P =.005) in the supine position, by 85.1% (P =.009) in the semirecumbent position, and by 40.2% (P =.005) in the sitting position. The corresponding results in the more severely affected leg in patients with varicose veins were 71.9% (P =.005) in the supine position, 77.9% (P =.005) in the semirecumbent position, and 55.7% (P =.013) in the sitting position. Similar improved results were also found in the contralateral leg in both groups. CONCLUSIONS: The deflation settings of the new SCD Response System are able to be adjusted selectively, correlating with the physiological severity of chronic venous insufficiency. By achieving more frequent compression cycles, the new system is more effective than the current one in expelling blood proximally, confirming our earlier findings in healthy volunteers. Further studies testing a possible improved efficacy in preventing deep venous thrombosis in this high-risk group are justified.

Leukocyte rheology before and after chemotactic activation in some venous diseases.

OBJECTIVE: to evaluate leukocyte rheology, polymorphonuclear leukocyte (PMN) membrane fluidity and cytosolic Ca2+ concentration in subjects with post-phlebitic leg syndrome (PPS) and acute deep-venous leg thrombosis (DVT). SUBJECTS: twenty-two subjects with leg PPS and 14 subjects with leg DVT. METHODS: we evaluated the leukocyte filtration (unfractionated, mononuclear cells (MN) and PMN), the PMN membrane fluidity and the PMN cytosolic Ca2+ concentration. Subsequently, we evaluated the same PMN variables after in vitro chemotactic activation with 4-phorbol 12-myristate 13-acetate (PMA) and N -formyl-methionyl-leucyl-phenylalanine (fMLP). RESULTS: at baseline we observed a significant difference in the filtration variables of unfractionated and MN cells and in PMN cytosolic Ca2+ concentration. After activation, in normal subjects and subjects with PPS and DVT, a significant variation in PMN filtration at 5 and 15 minutes was evident. In normal subjects, no variation was present in PMN membrane fluidity or cytosolic Ca2+ concentration after activation. In subjects with PPS and DVT, we found a decrease in PMN membrane fluidity and an increase in PMN cytosolic Ca2+ concentration. After PMN activation (at 5 and 15 min) Delta% of IRFR distinguished normal subjects from subjects with PPS and DVT, while no difference was found in Delta% of membrane fluidity or cytosolic Ca2+ concentration. CONCLUSIONS: there is a functional alteration of leukocytes in these patients whose mechanisms are not yet clear.

The postthrombotic syndrome in relation to venous hemodynamics, as measured by means of duplex scanning and strain-gauge plethysmography.

PURPOSE: Venous hemodynamics were evaluated in relation to the postthrombotic syndrome (PTS) 7 to 13 years after deep venous thrombosis (DVT). METHODS: The presence of flow, reflux, and compressibility of 1394 vein segments in 82 patients was assessed by means of duplex scanning. The venous outflow resistance was measured by means of strain-gauge plethysmography. The venous hemodynamics were related to the clinical severity of the PTS, characterized by the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification. RESULTS: In patients with severe clinical symptoms of PTS, the prevalence of reflux was significantly higher. There was no relationship between the severity of the PTS and the noncompressibility or the combination of reflux and noncompressibility or an increased venous resistance. By means of multiple regression analysis with the variables of age, gender, reflux, and venous resistance, age and reflux were shown to be the main contributors to the severity of PTS. Significantly more patients (64%) with severe signs of PTS had a combination of deep and superficial reflux. In each of the traceable vein segments, the mean of the CEAP classification was calculated for the vein segments with and without reflux. In the proximal superficial femoral vein (P <.001), distal superficial femoral vein (P <.05), and popliteal vein (P <.05), a significantly higher mean CEAP classification was found in the veins with reflux, whereas in the distal, long, and short saphenous veins, no such relationship was found. CONCLUSION: Most patients with severe PTS had a combination of deep and superficial reflux. Reflux in the deep proximal veins contributes significantly to the PTS.

Light reflection rheography and clinical course of patients with advanced venous disease before and after endoscopic subfascial division of perforating veins.

BACKGROUND: Endoscopic subfascial division of perforating veins (ESDP) has been shown to cause fewer surgical complications than classic techniques. OBJECTIVE: To evaluate the efficacy of ESDP based on patients' symptoms, rheographic data, and ulcer healing. METHODS: Thirty-two subsequent patients underwent 40 ESDP procedures. Fifteen limbs presented with a postthrombotic syndrome (PTS), and 16 cases had an active venous ulcer. Data were recorded before and 2 months after ESDP. Stripping or high ligation procedures had been previously performed. RESULTS: The symptoms of pain and edema improved in 80% (PTS) and 74% (venous ulcer) of patients. Only one case did not show improvement of either pain or edema. Fifty-eight percent of patients showed hemodynamic improvement by light reflection rheography (LRR), while 32% did not change and 10% of patients had a worsened LRR after ESDP. The LRR refilling times increased by a median factor of 1.69, reaching at least 20 seconds in nine of 40 limbs. Venous ulcers that had been active for a median of 12 years (range, 0.5-21) healed in nine of 16 cases within 14-50 days (median, 21 days). CONCLUSION: ESDP reduces disease-related symptoms, improves hemodynamics in almost 60%, and facilitates healing of long lasting venous ulcers.

Axial transformation of the profunda femoris vein.

PURPOSE: To highlight a special subset of cases of venous stasis in which the profunda femoris vein enlarges to a variable extent (axial transformation) to compensate for severe postthrombotic changes in the accompanying superficial femoral vein. METHODS: Among 500 consecutively treated patients with severe venous stasis, 57 patients had axial transformation of the profunda femoris vein. Venous obstruction and reflux were assessed by means of arm-foot pressure differential, ambulatory venous pressure measurement, air plethysmography, and duplex examination. Ascending and descending venograms also were obtained. A variety of valve reconstruction techniques were useful in correcting reflux in the enlarged profunda femoris vein and the companion postthrombotic superficial femoral vein. RESULTS: In 55% of patients the profunda femoris vein was larger than normal and provided partial outflow from the leg through a profunda-popliteal connection, but the superficial femoral vein was still the dominant outflow tract (grades I and II). In 36% of patients the profunda femoris was the dominant outflow tract from the leg, and in another 9% it was the sole axial outflow tract (grades III and IV). The skin changes of advanced venous stasis were present among 92% of patients and frank ulceration among 88%. Antireflux operations on the profunda femoris vein and companion superficial femoral vein, including ligation and division in some instances, were well tolerated. Despite a postthrombotic cause, obstruction did not worsen after surgical treatment, and reflux improved according to most laboratory measurements. Complete ulcer healing was obtained with the surgical techniques described. The actuarial recurrence-free survival rates were 90% 1 year and 66% 5 years after treatment. CONCLUSION: Axial transformation of the profunda femoris vein is present in a subset of instances in which severe postthrombotic changes are present in the companion superficial femoral vein. Profunda femoris reflux is invariably present in these instances because of compensatory dilatation and enlargement of this vessel. Simultaneous valve repair of the axially transformed profunda femoris vein and companion superficial femoral vein to abolish reflux yields excellent long-term results and healing of stasis ulceration.

Saphenous vein thrombophlebitis (SVT): a deceptively benign disease.

PURPOSE: The association between deep vein thrombosis (DVT) and the hypercoagulable state is a well-established entity. However, the association between saphenous vein thrombophlebitis and coagulation abnormalities has not been investigated. Although thrombosis of varicose veins typically runs a benign course, phlebitis of the saphenous system may propagate to the deep system or saphenofemoral junction that requires more aggressive therapy. Given the potential similarity in clinical outcome between saphenous vein thrombophlebitis (SVT) and DVT, we have investigated the coagulation profile of patients presenting with isolated SVT. METHODS: Seventeen consecutive patients who presented to our vascular laboratory with isolated SVT had a coagulation profile performed that included antithrombin III (AT III), protein C (PC), protein S (PS) antigen and activity levels, activated protein C (APC) resistance, factor V DNA mutation, and coagulation factors II and X. All patients had duplex scans performed on both the superficial and deep venous systems. Patients with SVT only were treated with nonsteroidal antiinflammatory drugs (NSAIDs) and warm soaks as outpatients, whereas those patients found to have DVT or a clot at the saphenofemoral junction were fully anticoagulated with heparin and coumadin therapy. All 17 patients had at least one repeat coagulation profile performed up to 5 months after their SVT occurrence to ensure that the results of hypercoagulability were not transient. RESULTS: Ten (59%) of the 17 patients with SVT had abnormal coagulation profiles on initial presentation. All 10 patients who were hypercoagulable had repeat tests and 6 (35%) remained abnormal. Four patients who had abnormal results converted to normal values. Seven patients with normal coagulation profiles on initial presentation had repeat tests and all remained normal. CONCLUSION: The incidence of the hypercoagulable state in patients with SVT is high. Thirty-five percent of patients with isolated SVT had consistently abnormal coagulation profiles. Patients with SVT may be prone to the development of DVT or saphenofemoral junction thrombophlebitis and should be closely followed after the initial diagnosis of hypercoagulability.

[Physical factors in the combined treatment of patients with postthrombophlebitic disease of the legs]. / Fizicheskie faktory v kompleksnom lechenii bol'nykh s posttromboflebiticheskoi bolezn'iu nog.

95 patients with postthrombophlebitis affection of the lower limbs were treated according to three schemes: conventional therapy alone (anticoagulants, anti-inflammatory therapy, etc.), training of collateral circulation plus minimal standard chemotherapy, training of collateral circulation plus local and endovasal laser radiation plus minimal standard chemotherapy. A total of 75 patients were treated (27, 32 and 36 patients of group 1, 2 and 3, respectively). The best results were achieved in group 3.

Pathogenesis and pathophysiology of the post-thrombotic syndrome: clinical implications.

Anticoagulant therapy can successfully prevent pulmonary embolism and rethrombosis in most cases, but cannot affect either early morbidity or the late post-thrombotic sequelae. In carefully selected cases, early clot removal by thrombolysis or thrombectomy may be justified by improved outcome because of the significant role early and late outflow obstruction plays in determining the ultimate severity of post-thrombotic sequelae. Nevertheless, it is recognized that anticoagulant therapy will continue to be used in the majority of patients because of serious intercurrent disease, sedentary lifestyle, limited extent of thrombosis, lack of tissue loss and, unfortunately, delay in referral for treatment.

Microcirculation in high perfusion microangiopathy.

Using laser-Doppler flowmetry in association with other noninvasive microcirculatory techniques such as transcutaneous PO2 and PCO2 and capillary filtration measurements it is possible to define two major types of microangiopathy. Low perfusion microangiopathy (LPM) is observed in peripheral vascular disease, essential hypertension, Raynaud's disease etc. High perfusion microangiopathy (HPM) is observed in venous hypertensive microangiopathy and diabetic microangiopathy. In both these conditions there is an increased skin flux, decreased venoarteriolar response and increased capillary filtration leading to edema formation. In HPM elastic compression and drugs acting on capillary filtration effectively reduce skin flux and the increased capillary leakage and edema formation.

[Ambulatory treatment of postphlebitic ulcers of lower limbs. Physiopathological bases and clinical results]. / Il trattamento ambulatoriale delle ulcere postflebitiche degli arti inferiori. Basi fisiopatologiche e risultati clinici.

Venous ulceration is a troublesome and disabling complication, representing one of the most difficult problems to be treated by the vascular surgeon. Venous insufficiency is a widespread condition, the prevalence of venous ulceration being 0.5 - 1 per cent in European populations. Although all venous ulcers will heal if the limb is elevated above heart level for an extended period of time, patients need a safe, effective, not disabling and quick therapy. Hence, the competent vascular surgeon must be familiar with venous pathophysiology and possess a thorough understanding of the treatment options available for a discouraged patient in need of an acceptable and effective approach. The aim of the present study was to assess the efficacy and the speed of healing of venous ulcer using an outpatient ambulatory treatment protocol. This protocol consisted of elastic compression bandage allowing deambulation, local dressing using lyophilized heterologous collagen (Condress, Gentili) and systemic profibrinolytic drugs. Exclusion criteria were coexisting arterial insufficiency, ulcer area greater than 25 cm2, coexisting disabling diseases (congestive cardiac failure, hepatic insufficiency, malignancy). From December 1990 to June 1993, 37 patients affected by venous ulcer were treated, according to the aforementioned protocol, at the Surgical Department of Montecchio Maggiore Hospital (VI). There were 16 male and 21 female patients, mean age was 66 years (range 59-91). Results show the complete healing of the venous ulcer in 94.5% of patients; mean time for ulcer healing was 128 days (range 45-91). The Authors conclude that the outpatient ambulatory treatment protocol is safe, quick, and effective for the therapy of chronic venous ulcer; once obtained the healing of the ulcer, elastic compressive bandage with elastic stockings is mandatory to prevent recurrences.

Venous reflux in patients with previous deep venous thrombosis: correlation with ulceration and other symptoms.

PURPOSE: Deep vein thrombosis (DVT) in many cases leads to chronic symptoms in the damaged leg, even though the affected veins have recanalized. The major hemodynamic defect in such recanalized veins is reflux. The incidence and extent of reflux has been studied in patients with proven DVT and correlated with concurrent symptoms. METHODS: Two hundred seventeen limbs in 183 patients were examined by duplex scanning from January 1989 to October 1992. All limbs had previous DVT diagnosed by venography. Sites and extent (proximal, distal, or both) of reflux were identified by meticulous duplex scanning of the whole venous system and correlated with presenting symptoms. RESULTS: The patients were classified into nine groups on the basis of the classification of the system involved (superficial, deep, or superficial and deep) and whether the reflux was found proximal or distal to the knee or both. Eight-one limbs belong to chronic venous insufficiency class 1, 92 belong to class 2, and 38 belong to class 3. Reflux was confined to the deep venous system in 84 limbs (38.7%), to the superficial system in 31 (14.3%) limbs, and to both systems in 102 (47%) limbs. It was confined to proximal veins only in 48 (22.1%) limbs, distal only in 56 (25.8%) limbs and throughout the limb in 113 (52.1%) limbs. The incidence of swelling was increased by distal or a combination of proximal and distal reflux regardless of which system was involved. In limbs with superficial venous insufficiency (SVI) or deep venous insufficiency (DVI) only, the incidence of skin changes was not affected by the extent of reflux. However, in limbs with combined SVI and DVI, it was increased in the presence of reflux throughout the limb. Absence of distal reflux was associated with a low incidence of skin changes even in the presence of DVI. Ulceration increased with an increased extent of reflux in the presence of SVI. Absence of superficial reflux was associated with a low incidence, even in the presence of DVI. CONCLUSIONS: The data suggest that as far as the skin changes and ulceration are concerned, distal reflux and reflux in the superficial veins are more harmful than reflux confined to the deep veins, even when such reflux extends throughout the deep venous system.

Long-term results of venous valve reconstruction: a four- to twenty-one-year follow-up.

PURPOSE: The purpose of this study is to describe the very long-term clinical, hemodynamic, and imaging results of venous valve reconstruction for reflux disease in patients with chronic venous insufficiency. METHODS: There were 51 extremities (48 patients) with follow-up of 4 to 21 years with a mean of 10.6 years. Clinical severity was graded as asymptomatic (class 0), mildly symptomatic (class 1), moderately symptomatic but without ulceration (class 2), or severely symptomatic with or without ulceration (class 3). Preoperative and postoperative evaluation consisted of history and physical examination, ascending venography (preoperative only), ambulatory venous pressures or photoplethysmography, and descending venography or duplex scanning. RESULTS: Before surgery, 49 (96%) of 51 limbs demonstrated severe, class 3 disease, and two limbs were classified as class 2 disease. After venous valve reconstruction by either direct femoral vein valve repair, transposition, or transplantation, long-term clinical success of achieving a class 0 or 1 result (by life-table analysis) was 60% at 10 years. Thirty-three percent demonstrated a class 0 result in which the limbs were free from symptoms and had no need for long-term elastic support. After 6 years clinical results were stable and did not deteriorate. Incompetent perforators were identified in 31 cases and were treated selectively. Three disease patterns of chronic venous insufficiency were identified: primary valve insufficiency 43%, postthrombotic syndrome 31%, and a group consisting of both primary valve insufficiency of the superficial femoral vein and postthrombotic syndrome of the calf veins (primary valve insufficiency-postthrombotic syndrome) 26%. Ten-year cumulative clinical success was clearly superior in limbs with primary valve insufficiency corrected by valve repair (73%) as opposed to those with postthrombotic syndrome treated by either valve transposition or transplantation (43%) (p = 0.029). Clinical outcome correlated strongly with postoperative imaging results, and durability of valve repair was confirmed by demonstrating competence up to 16 years after the operation. Significant improvement in ambulatory venous pressure (mean percentage of pressure fall and refill time) was found in limbs with class 0 or 1 outcome; however, values did not reach "normal" levels in all cases. Recurrent ulcerations after the operation were attributed to failed reconstructions (10), incompetent profunda femoris veins (three), incompetent perforators (three), and concomitant lymphedema (one). CONCLUSIONS: This report highlights a difference found in very long-term prognosis of surgical treatment of primary valve insufficiency as opposed to postthrombotic syndrome. Long-term elimination of symptoms of chronic venous insufficiency is achieved by valve repair for primary valve insufficiency beyond 10 years, whereas late results of treatment of postthrombotic syndrome in this study was accompanied by high recurrence rates and warrants further investigation.