Haemodynamic and clinical impact of superficial, deep and perforator vein incompetence.

OBJECTIVE: The purpose of this study was to assess the effect of venous incompetence of the deep, superficial and perforator veins combined (i.e. multi-system incompetence) on the venous haemodynamics and clinical condition of limbs with chronic venous disease (CVD). METHODS: One hundred and thirty two limbs (16-C(1); 30-C(2); 20-C(3); 25-C(4); 21-C(5); 20-C(6)) of 121 patients were studied. We excluded those with previous venous surgery/sclerotherapy, peripheral arterial disease, recent deep vein thrombosis (< or =6 months), or inability to comply with the tests. The CEAP clinical class was assessed. Duplex ultrasonography (ultrasound) enabled classification according to: the presence of superficial([S]) (+/- perforator([P])) or deep([D]) (+/-S, +/-P) reflux (>.5s); the number of incompetent venous systems (single-system([S/P/D]), dual-system([S+P/S+D/P+D]), or triple-system([S+P+D])), and the number of incompetent perforators([0/1/2/> or =3]). The amount of reflux (Venous Filling Index([VFI])); calf pump Ejection Fraction([EF]), and Residual Volume Fraction([RVF]) were studied with air-plethysmography. RESULTS: VFI in limbs with triple-system incompetence (VFI median 6.68 [IQR: 4.7-9.7]ml/s) was higher than in limbs with dual-system incompetence (4.5 [2.1-7.4]ml/s), and VFI in the latter was higher than in limbs with single-system incompetence (1.3 [0.69-2.3]ml/s)(p<0.01 Kruskal-Wallis). Although EF changes were small, RVF in limbs with triple-incompetence (39 [30-51] %) was higher than in single-system incompetence (26 [16-33] %)(p<0.01 Mann-Whitney). Limbs with superficial (+/-P) incompetence had a lower VFI (p<0.01) and RVF (p<0.02) than limbs with deep (+/-S+/-P) incompetence, and limbs with > or =2 incompetent perforator veins had a higher VFI (p<0.04) than those without perforators. All limbs with single-system incompetence were C(1-3,) whereas 78% of those with triple-incompetence were C(4-6) (p<0.01). The number of incompetent systems increased with clinical class (p<0.01). CONCLUSIONS: The frequency of incompetence of more than one venous system increased with the clinical severity of venous disease and was accompanied by a 5-fold increase in the amount of reflux and a 50% rise in the RVF. The number of incompetent perforators per limb increased with the amount of reflux. The number of incompetent venous systems (superficial, deep, perforator) and perforator veins can be assessed by duplex ultrasound giving an objective indication of the functional severity of venous disease. In this way duplex ultrasound could be used to grade venous function in clinical practice as an alternative to APG measures which are less widely available.

Prevalence and distribution of incompetent perforating veins in chronic venous insufficiency.

PURPOSE: The purpose of this study was the investigation of the prevalence and distribution of incompetent perforating veins (IPVs) in patients with different classes of chronic venous insufficiency (CVI) as defined by the updated clinical, etiologic, anatomic, and pathologic classification (CEAP) in relation to the pattern and the extent of venous reflux. MATERIAL AND METHODS: The study included 468 limbs of 330 subjects who ranged in age from 18 to 101 years (median, 49 years). The investigation entailed a medical history, a clinical examination, and color flow duplex imaging of the lower limb veins, which were performed by the same vascular surgeon operator. The patients were classified into 7 clinical classes according to CEAP. The superficial and deep venous systems were scanned, with an emphasis on the detection of IPVs. Venous reflux was considered abnormal when its duration exceeded 0.5 seconds. IPVs were classified as medial, posterior, and anterolateral in the upper, middle, or lower third of the thigh or calf (9 thigh and 9 calf fields). RESULTS: The IPVs were found mainly in the medial aspect, more frequently in the middle third of calf, followed by the lower calf and the middle thigh. IPVs were rare in the lateral aspect of the thigh, the medial upper and posterior lower thigh and the posterior upper and lower calf. The prevalence of the IPVs and of deep vein incompetence increased significantly with the clinical severity of CVI (r =.95, P <.01, and r =.9, P <.01, respectively). In the limbs with a documented perforating vein (PV) incompetence, the ratios of calf-to-thigh IPVs and of superficial-and-deep (S + D) over superficial-alone (S; [S + D]/S] venous incompetence increase significantly (r =.87, P <.01 and r =.9, P <.01, respectively) with CEAP grade. The prevalence of reflux involving all systems (S + D + PV) increases significantly (r =.9, P <.01) with clinical severity. In legs with CVI of CEAP 2 to 6, reflux was invariably proximal (thigh) and distal (below knee). CONCLUSION: In CVI, IPVs are located predominately in the medial aspect of the lower extremity, more often in the middle third of the calf, followed by the lower calf and middle thigh. The prevalence of IPVs and their calf-to-thigh ratio increase linearly with the clinical severity of CVI. Both the prevalence of deep vein incompetence and the ratio of superficial and deep to superficial ([S + D]/S) increase linearly with CEAP classification. These findings support the significant relationship between deep venous reflux and PV incompetence, although the latter may exist in the absence of the former. In CEAP classes 2 to 6, reflux is invariably proximal and distal. Incompetence involving all systems (S + D + PV) increases in prevalence with the severity of CVI.

Effect of lightweight compression stockings on venous haemodynamics.

OBJECTIVE: To investigate the effect of lightweight graduated elastic stockings on venous haemodynamics. DESIGN: The amount of reflux and function of the calf muscle pump were evaluated before and after the application of lightweight graduated compression stockings using air-plethysmography. Each patient acted as his own control and the Wilcoxon rank sum test was used. SETTING: Vascular laboratory of a teaching hospital. SUBJECTS: 19 female patients (20 limbs) with moderate varicose veins. MAIN OUTCOME MEASURES: The haemodynamic parameters: amount of reflux (VFI), ejection fraction (EF) of the calf muscle pump after one tiptoe exercise, residual volume fraction (RVF) after 10 tiptoes and venous volume (VV) were determined for each patient with and without the three strengths of stocking (7, 10, 14 mmHg at the ankle) using air-plethysmography. RESULTS: The mean VFI decreased from 5.7 ml/sec without stockings to 4.6+/-2.2, 3.9+/-2.3, and 3.4+/-1.8 with stockings of 7, 10 and 14 mmHg respectively (p<0.0002). Similarly the RVF showed a significant decrease with all three stockings from the initial value 42.3% to 36.3, 34.4 and 31.5 respectively (p<0.03). EF showed an increase from 49.2% to 51.4, 50.9 and 56, but only with the latter was the increase significant (p<0.02). VV decreased from 118.8 ml to 113.6+/-24.4 (p>0.05), 104.2+/-22.8 and 109.1+/-27.4 (p<0.008) with 10 and 14 mmHg. CONCLUSIONS: The results indicate that lightweight compression stockings can have a significant effect on venous haemodynamics. They decrease the residual volume fraction and by inference ambulatory venous pressure. This is the result of an increase in the ejection fraction with a decrease of reflux. The results offer a possible physiological explanation on the relief of symptoms experienced when patients with varicose veins wear lightweight stockings.

Venous elasticity after treatment with Daflon 500 mg.

It has been demonstrated that patients predisposed to the development of varicose veins have an abnormal venous tone, and may have symptoms in the absence of obvious varicosities. It has been suggested that venotonic drugs relieve the symptoms of chronic venous insufficiency by decreasing capillary leakage and improving venous tone. The aim of this study was to determine the effect of Daflon 500 mg in patients with abnormal venous elasticity without varicose veins. Twenty-five healthy female volunteers aged 18-35 were included in the study. They presented with symptomatic varicose veins in one leg and an abnormal elastic modulus without varicosities in the opposite leg. Treatment group: 12 patients received 2 tablets of Daflon 500 mg (1000 mg/day); control group: 13 patients received no treatment. The elastic modulus K was determined using the air plethysmograph. Simultaneous measurements of calf volume changes were made in response to different venous pressures produced by a thigh pneumatic cuff. In the control group K (mean +/- sd) was 10.8 x 10(3) +/- 4.1 x 10(3) N/m2 at the beginning and 10.2 x 10(3) +/- 3.1 x 10(3) N/m2 at the end of the study (P > 0.1). In the treatment group the initial K was 10.2 x 10(3) +/- 3.9 x 10(3) N/m2 and 14.2 x 10(3) +/- 5.1 x 10(3) N/m2 at the end (P < 0.02). The results of the Wilcoxon rank sum test indicated that 4 weeks' therapy with Daflon 500 mg is effective in improving venous tone in patients with symptoms but without varicose veins.

Effects of GABAA receptor ligands on noradrenaline concentration and beta-adrenoceptor binding in mouse cerebral cortex.

The present experiments investigated changes in beta-adrenoceptor binding and noradrenaline stores in mouse cerebral cortex after single treatments with drugs which bind to the GABAA receptor but which attenuate the actions of GABA. Neither the GABA antagonist, securinine, nor the picrotoxin/Cl- channel ligand, picrotoxin, affected noradrenaline levels or beta-adrenoceptor binding. However, both the benzodiazepine inverse agonist, DMCM, and pentylenetetrazole increased noradrenaline levels 24 h after injection. Only pentylenetetrazol modified beta-adrenoceptor binding: there was a significant increase in receptor number 4 days after injection, but a significant decrease after 7 days. The anxiogenic, proconvulsant drug, yohimbine, was without effect. The changes induced by DMCM and pentylenetetrazole do not seem to be related to the behavioural effects of these drugs or to their affinity for binding to benzodiazepine receptors. The possibility that these compounds have actions in addition to those at the GABAA receptor is discussed.