Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence.

There are excellent guidelines for clinicians to manage venous diseases but few reviews to assess their hemodynamic background. Hemodynamic concepts that evolved in the past have largely remained unchallenged in recent decades, perhaps due to their often complicated nature and in part due to emergence of new diagnostic techniques. Duplex ultrasound scanning and other imaging techniques which evolved in the latter part of the 20th century have dominated investigation. They have greatly improved our understanding of the anatomical patterns of venous reflux and obstruction. However, they do not provide the physiological basis for understanding the hemodynamics of flow, pressure, compliance and resistance. Hemodynamic investigations appear to provide a better correlation with post-treatment clinical outcome and quality of life than ultrasound findings. There is a far better prospect for understanding the complete picture of the patient's disability and response to management by combining ultrasound with hemodynamic studies. Accordingly, at the instigation of Dr Angelo Scuderi, the Union Internationale de Phlebologie (UIP) executive board commissioned a large number of experts to assess all aspects of management for venous disease by evidence-based principles. These included experts from various member societies including the European Venous Forum (EVF), American Venous Forum (AVF), American College of Phlebology (ACP) and Cardiovascular Disease Educational and Research Trust (CDERT). Their aim was to confirm or dispel long-held hemodynamic principles and to provide a comprehensive review of venous hemodynamic concepts underlying the pathophysiology of lower limb venous disorders, their usefulness for investigating patients and the relevant hemodynamic changes associated with various forms of treatment. Chapter 1 is devoted to basic hemodynamic concepts and normal venous physiology. Chapter 2 presents the mechanism and magnitude of hemodynamic changes in acute deep vein thrombosis indicating their pathophysiological and clinical significance. Chapter 3 describes the hemodynamic changes that occur in different classes of chronic venous disease and their relation to the anatomic extent of disease in the macrocirculation and microcirculation. The next four chapters (Chapters 4-7) describe the hemodynamic changes resulting from treatmen by compression using different materials, intermittent compression devices, pharmacological agents and finally surgical or endovenous ablation. Chapter 8 discusses the unique hemodynamic features associated with alternative treatment techniques used by the CHIVA and ASVAL. Chapter 9 describes the hemodynamic effects following treatment to relieve pelvic reflux and obstruction. Finally, Chapter 10 demonstrates that contrary to general belief there is a moderate to good correlation between certain hemodynamic measurements and clinical severity of chronic venous disease. The authors believe that this document will be a timely asset to both clinicians and researchers alike. It is directed towards surgeons and physicians who are anxious to incorporate the conclusions of research into their daily practice. It is also directed to postgraduate trainees, vascular technologists and bioengineers, particularly to help them understand the hemodynamic background to pathophysiology, investigations and treatment of patients with venous disorders. Hopefully it will be a platform for those who would like to embark on new research in the field of venous disease.

Value of postoperative compression after mini-invasive surgical treatment of varicose veins.

OBJECTIVE: It is customary to recommend wearing elastic band compression or compression stockings after treatment of varicose veins. Our aim was to evaluate the benefit from wearing elastic compression stockings after surgical treatment of varicose veins. METHODS: Prospective nonrandomized study with inclusion of consecutive patients operated on for unilateral varicose veins during a 6-month period with distribution in two groups: group 1, in which the patients were wearing an 18-mm Hg thigh compression stocking from the day of the operation until the postoperative consultation and group 2, in which the patients were wearing an 18-mm Hg thigh compression stocking for only 36 hours after surgery. The evaluation of outcomes was made at the postoperative consultation and concerned pain (self-evaluation by visual analog scale) and analgesic consumption, ecchymosis (self evaluation by visual analog scale), edema (circumference of the ankle), deep or superficial venous thrombosis (ultrasound duplex), quality of life by Chronic Venous Insufficiency Quality-of-Life questionnaire, and duration of postoperative sick leave. RESULTS: Fifty patients were included in each group for a total of 100. There was no significant difference between the two groups with regard to demographics, to clinical and hemodynamic characteristics, and to the type of surgery performed (phlebectomy, 32% vs 32%; ambulatory selective varices ablation under local anesthesia, 46% vs 48%; stripping, 10% vs 12%; redo surgery for recurrence, 12% vs 8%). All the surgical procedures were carried out under tumescent local anesthesia. At the postoperative consultation, we did not observe any significant difference between group 1 and group 2 for pain score (0.6 vs 0.8; P = .35), analgesic consumption frequency (8% vs 12%; P = .50), ecchymosis score (1.3 vs 1.2; P = .49), and quality-of-life score (7.00 vs 8.64; P = .43). The circumference of the ankle was not significantly different for the side operated on before and after surgery, for group 1 (25.6 cm vs 26.2 cm; P = .30) and for group 2 (25.5 cm vs 26.2 cm; P = .28). No superficial or deep vein thrombosis was found. There was no difference in sick leave frequency (26.7% vs 32.3%; P = .57) and duration (2.6 vs 2.3 days; P = .83). CONCLUSIONS: We found no benefit from wearing the compression stocking beyond the first postoperative day for pain, ecchymosis, quality of life, and thrombosis after a mini-invasive surgical treatment for varicose veins carried out under tumescent local anesthesia with immediate ambulation.

Retrospective evaluation of the need of a redo surgery at the groin for the surgical treatment of varicose vein.

BACKGROUND: Surgical treatment for varicose recurrence (STVR) involves removing all sources of reflux from the deep venous network to the superficial venous network. STVR is usually more complex and aggressive than first-line treatment by stripping, particularly for redo surgery at the groin (RSG). This retrospective study compared traditional STVR and a less aggressive surgical approach focusing on treatment of the varicose reservoir and avoiding RSG if possible. METHOD: Two successive periods of STVR after great saphenous vein stripping were compared: traditional STVR (T1) and STVR focusing on the varicose reservoir (T2). We reviewed postoperative complications and studied the hemodynamic and clinical results. RESULTS: During T1 and T2, we operated 473 legs in 288 patients (236 women, 52 men) to treat varicose recurrence after great saphenous vein stripping. Mean age was 60.83 years (range, 28-88 years). We operated on 137 patients during T1 and 151 during T2. Patients had similar demographic data, CEAP classification, and Venous Disability Score. Inguinal reflux occurred in 73.9% of T1 patients and in 74.4% of T2 patients. We performed RSG in 66.0% of T1 patients and in 2.2% of T2 patients (P < .05). We did not use echo-guided sclerotherapy in addition to primary STVR. Tumescent local anesthesia was used in 96.2% of STVR in T2 vs 4.0% in T1 (P < .05), and 95.3% of T2 procedures were outpatient vs 13.7% of T1 (P < .05). Outcomes of limbs presenting an inguinal reflux treated with RSG during T1 (group 1) and without RSG during T2 (group 2) were compared. Postoperative complications occurred in 6.7% in group 1 vs 0.5% in group 2 (P < .05), with inguinal complications predominating. The mean cost of the procedure per limb was euro1,195.88 in group 1 vs euro863.08 in group 2 (P < .0001). After 3 years of follow-up, Kaplan-Meier life-table analysis showed group 1 and 2 patients had similar rates of freedom from inguinal reflux (90.8% vs 92.9% survival rate) and from varicose repeat-recurrence (90.8% vs 91.9% survival rate). Group 1 had better results for the Venous Disability Score (0.38 vs 0.58, P = .02) and cosmetic improvement (94.2% vs 84.2%; P = .00032). CONCLUSION: STVR focusing on the varicose reservoir and avoiding RSG led to a minimally invasive procedure and a reduction in postoperative complications, with good medium-term clinical and hemodynamic results, particularly for symptoms improvement and cosmetic appearance, with a lower cost vs traditional STVR with RSG.

Midterm results of the surgical treatment of varices by phlebectomy with conservation of a refluxing saphenous vein.

BACKGROUND: A new physiopathologic concept within superficial venous insufficiency (SVI) describes ascending progression from the collaterals to the saphenous veins (SV), leading to a treatment that aims to remove the varicose reservoir and not the SVs. This study reports the midterm results of this therapeutic approach. METHODS: This is a retrospective study of patients treated for varices by phlebectomy with conservation of a refluxing SV before July 2004. We evaluated the varicose reservoir by determining the number of zones to be treated (NZT); each lower limb was divided into 32 zones in the preoperative mapping. We performed a clinical and duplex ultrasound examination after 6 months and 1 year, and then once a year until year 4. RESULTS: Amongst 811 lower limbs operated on for first-time varicose veins, 303 in 221 patients (55 men; 166 women), mean age, 52.7 years (range, 20-93 years), were treated by phlebectomy, with conservation of a refluxing SV. All lower limbs operated on presented preoperative SV reflux >0.5 seconds: great SV (GSV), 85.8%; small SV (SSV), 11.9%; and GSV and SSV, 2.3%. The average NZT was 6.05 (range, 2-10). SV reflux was reduced to < 0.5 seconds in 69.6%, 69.2%, 68.7%, 68.0%, and 66.3% of limbs, respectively, after 6 months, 1, 2, 3, and 4 years of follow-up. Symptoms improved or disappeared in 84.2%, 84.2%, 83.4%, 81.4%, and 78.0% of limbs at each annual check-up until year 4. Freedom of varices recurrence was 95.5%, 94.6%, 91.5%, and 88.5%, respectively at 1, 2, 3, and 4 years. When the NZT was >7, the postoperative varicose recurrence was more frequent (odds ratio, 6.82; P = .0001), and the postoperative elimination of SV reflux was more frequent (odds ratio, 4; P = .037) as was symptoms improvement (odds ratio, 2.91; P = .004). When an ostiotruncal SV reflux extended to the malleolus preoperatively, the elimination of the SV reflux was less frequent (47.6% vs 70.3%; P < .05). CONCLUSION: Ablation of the varicose reservoir with conservation of a refluxing SV can be an effective treatment in the midterm for the signs and symptoms of SVI and leads to nonsignificant SV reflux in more than two of three cases. The extent of the varicose reservoir ablation is the key factor determining the hemodynamic and clinical efficacy of this more limited surgical approach.

Great saphenous vein stripping with preservation of sapheno-femoral confluence: hemodynamic and clinical results.

BACKGROUND: Radiofrequency and laser vein treatment, which entail preservation of the saphenous confluence, have called into question the dogma of ligation of all tributaries at the sapheno-femoral confluence (SFC), so called "crossectomy". Nevertheless, crossectomy is still done when saphenous vein stripping is chosen for varicose vein treatment. The purpose of this study was to evaluate results after stripping procedures in which the SFC was preserved. METHODS: This was a retrospective cohort study for which limbs treated for varicose veins by surgical stripping of the great saphenous vein and preservation of the SFC were studied. All limbs had a preoperative duplex examination and showed SFC and truncal incompetence of the great saphenous vein. Periodic postoperative standing duplex ultrasound and clinical examinations were carried out, and results were recorded and analyzed retrospectively. RESULTS: A total of 195 lower limbs were operated on in 151 patients (128 women and 25 men) aged from 22 to 88 years (mean age 56.8). The preoperative diameter of the SFC ranged from 4.7 to 17 mm (mean 9.5 mm). The preoperative CEAP class distribution was C1 1.5%, C2 82.1%, C3 6.7%, and C4-C6 9.7%. Preoperative symptoms were present in 61.8% of cases. Postoperative thrombosis of the SFC was observed in one case with an extension to the deep femoral vein and pulmonary embolization at 1 month. Recovery was complete. At a mean of 24.4 months postoperatively (median 27.3 months, range 8 to 34.8), persistent SFC reflux was observed in only two cases (1.8%) and a SFC neovascularization in one case (0.9%). Recurrence of varicose veins appeared in seven cases (6.3%) but in conjunction with SFC reflux in only one case. Post treatment 83.9% of limbs were converted to CEAP clinical class 0 to 1 and significant symptom improvement was observed in 91.3% of cases with an aesthetic benefit in 95.5%. CONCLUSION: Preservation of the SFC during saphenous stripping gave good results with regard to hemodynamics and neovascularization on the SFC, varicose vein recurrence, improvement of symptoms, and aesthetic appearance for legs with a median follow-up of 27.3 months.