Distribution of valvular incompetence in patients with venous stasis ulceration

Distribution of valvular incompetence in patients with venous stasis ulceration Lawrence M. Hanrahan, MD, Clifford T. Araki, PhD, Agustin A. Rodriguez, MD, Gregory J. Kechejian, MD, Wayne W. LaMorte, MD, PhD, and James O. Menzoian, MD, Boston, Mass. Valvular incompetence associated with venous ulceration can occur in the superficial, deep, or perforating systems. Duplex imaging was used to evaluate 95 extremities (78 patients) with current venous ulceration to determine the location of incompetence in each extremity. In addition, in 91 of the 95 extremities the area of the venous ulcer was evaluated for the presence of perforating veins or any other superficial veins or both conditions. Sixty-three (66.3%) of the 95 extremities had multisystem incompetence (superficial and perforating plus superficial and deep plus perforating and deep plus superficial and perforating and deep), whereas single system incompetence (superficial plus perforating plus deep) was seen in only 26 (27.3%). Isolated deep incompetence was identified in only two extremities (2.1%). Furthermore, 45% (41/91) of the ulcers had no duplex evidence of any venous abnormality in the ulcer bed. These data show that the site of valvular incompetence occurred in multiple locations, that isolated valvular incompetence of the deep venous system was uncommon, and that perforating veins were not always in the ulcer bed itself. Because standard venous surgery has traditionally been directed toward only one system, this may provide one explanation for ulcer recurrence. Therefore complete venous evaluation with duplex imaging allowing for surgical intervention directed specifically to the sites of involvement in each system is recommended. (J VASeSuRG 1991;13:805-12.)

The underlying cause of the venous stasis syndrome has been an area of controversy for many years. With the advent of more sophisticated testing modalities, such as duplex imaging, renewed interest has been generated into the study of patients with this chronic condition. Although venous insufficiency has been associated with valvular incompetence, venous obstruction, calf muscle pump dysfunction, and arteriovenous connections, the exact role that each of these play in the overall genesis of the sequelae of venous stasis is uncertain. Specifically, the relative contribution of valvular incompetence of the superficial, deep, and perforating (communicating) systems in the genesis of venous insufficiency and ulceration has been difficult to determine. Multiple reports cite each of these systems alone, as the primary physiologic defect, From The Divisionof Surgery, Sectionsof Vascular Surgeryand Surgical Research, Boston University School of Medicine, Boston. Presentedat the SeventeenthAnnualMeetingof the New England Societyfor VascularSurgery,Newport,R.I., Sept. 13-14, 1990. Reprint requests: JamesO. Menzoian,MD, Divisionof Surgery, D-5, Boston UniversitySchoolof Medicine, 88 East Newton St., Boston,MA 02118. 24/6/28086

resulting in the development of numerous surgical approaches attempting to eliminate the defect of the appropriate system. 1-6 Complicating the matter even further, the various testing modalities used to study venous stasis disease, such as ambulatory venous pressures, photoplethysmography, impedance plethysmography, and handheld Doppler ultrasonography, have been useful for evaluating one or two systems but are rarely capable of evaluating all three systems reliably and accurately, s'78 The purpose of this article was to characterize the distribution of valvular incompetence of the superficial, deep, and perforating systems in extremities with current venous stasis ulceration. By use of duplex ultrasonography both the anatomic and functional aspects of all three systems, including the perforating veins, were evaluated simultaneously, and the exact distribution and location of valvular incompetence was determined. MATERIAL A N D M E T H O D S The superficial, deep, and perforating systems of 78 patients (95 extremities) with current venous stasis ulceration were evaluated by means of a standard high-resolution duplex imager (Biosound, 805

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Inc., Indianapolis, Ind.). Patients were from the Vascular Services of University Hospital and Boston City Hospital. The mean age of the group was 59 years (range, 24 to 88 years), and the group was comprised of 54 men (69%) and 24 women (31%). The mean duration of time since the patient claimed the ulcer first appeared was 94 months (range, 1 to 624 months). A history of superficial phlebitis or deep vein thrombosis or both was elicited in 33% of the patients. The incidence of other comitigating factors was as follows: pulmonary embolism, 12%; cancer, 13%; diabetes, 10%; intravenous drug abuse, 3%. Thirty-five percent of the 95 extremities studied had a history of previous lower extremity injury, and 34% had a history of previous surgery including superficial stripping; vena cava filter placement; or subfascial ligation of perforating veins via a stocking seam incision (Rob procedure) or via a medial incision (modified Linton procedure). In each of the extremities studied, the superficial, deep, and perforating systems were evaluated for the presence of acute or chronic thrombus, and valvular competency was then determined. Incompetency in each system was defined as demonstration of bidirectional flow elicited in any of the following ways: Valsalva maneuver; proximal and distal manual compression by the technician; and having the patient to blow up a rubber examination glove. In addition, milking of superficial veins by the technician was used to determine reflux in the superficial system. Occasionally the actual valve cusps were observed, and the determination of incompetency could be made visually. All patients were examined in a 60 degree reverse Trendelenberg position with most of the study being conducted with the patient in a supine position. The patient was placed in a prone position to examine the popliteal and lesser saphenous vein, as well as the gastrocnemius, soleal, and tibial veins.

Evaluation of superficial system The superficial system was divided into the following three regions to aid in the documentation and correlation of abnormalities: the above-knee greater saphenous vein, including the branches and main trunk, medially from the inguinal ligament to midpatella; the below-knee greater saphenous vein, including the branches and main trunk, medially from the midpatella to the medial maleolus; and the lesser saphenous vein (LSV), including the branches and main trunk, posteriorly from the popliteal space to the Achilles tendon. For the purposes of this study overall incompetence of the superficial system was

defined as any segment of superficial vein, whether branch or trunk, that exhibited bidirectional flow.

Evaluation of the deep system Areas specifically evaluated for valvular competence included the common femoral vein (CFV), superficial femoral vein, and the popliteal vein (POP V). Gross evidence of bidirectional flow classified a vein segment as incompetent. No attempt was made to quantitate the extent of incompetence (reflux) at each individual site. Overall incompetence of the deep system was defined as any evidence of gross bidirectional flow at any of the abovementioned sites. Evaluation o f the perforating system The specific technique of evaluating the perforating system has been previously described. 9 In each extremity this evaluation began at the medial aspect of the midthigh, identifying any vessels coursing from the superficial femoral vein to the greater saphenous vein or branches thereof. Attention was then directed to the calf where the entire medial, lateral, and posterior aspects were evaluated with the exception of the venous ulcer bed itself, which was evaluated at the end of the examination as described below. Perforating veins were defined as vessels that penetrated the fascia and constituted continuously traceable connections between the superficial and deep venous systems. Proof of their venous character was verified if vessel walls were easy to coapt with gentle external pressure from the ultrasound probe and if they exhibited no pulsatility. When a vessel was identified as a perforating vein, its location was recorded by use of a zone system similar to that described by Karkow et al/o and mapped on the leg with indelible marker. In brief, zone i is the area just above the inguinal ligament. Zones 2 to 4 are between the inguinal ligament and midpatella. Zones 5 to 8 are between midpatella and the malleoli, and zone 9 is the area just below the malleoli. Attention was then directed to its anatomic as well as fimctional characteristics. The internal diameter of the vessel was documented as well as any evidence of acute or chronic thrombus in its lumen. On rare occasions valves were seen in the perforator lumen, and valvular motion was elicited with manual compression of the calf by the technician. The corresponding vessels of the superficial and deep venous systems in continuity with the perforator were then identified. Venous flow characteristics were evaluated initially by directing the Doppler into the perforator

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lumen and listening to the flow signal while the patient breathed normally. The normal spontaneous and phasic signals frequently heard in the deep system are rarely heard in the perforating system, and more active measures are needed such as Valsalva maneuver or manual compression to elicit a signal. By use of these techniques valvular integrity was determined by documenting unidirectional (competent) or bidirectional (incompetent) flow. Ulcer bed evaluation The technique for duplex evaluation of the ulcer bed has been described in detail in a recent report. 9 In an attempt to evaluate the venous system underlying the venous ulcer itself and to keep the area as "clean" as possible, a technique was developed with a sterile surgical lubricant (Surgilube; E. Fougera & Co., Melville, N.Y.) and a transparent dressing (Bioclusive Transparent Dressing; Johnson & Johnson Products, Inc., New Brunswick, N.J.). The surface of the venous ulcer was covered first with sterile surgical lubricant to allow full coverage of the entire area of the wound. This is followed by complete coverage of the ulcer by use of the sterile transparent dressing taking care to eliminate all air pockets between the tissue surface and the dressing. Finally, a generous amount of sterile surgical lubricant is applied to the surface of the dressing. We have found that this technique allows for excellent transmission of the ultrasound beam and protects the ulcer from any additional bacterial contamination. The ulcer bed is then evaluated in the same manner as described above. In this study the ulcer bed of each extremity was evaluated for both perforating veins and superficial vessels. Superficial vessels were defined as any veins observed by duplex scanning to pass through the ulcer bed, or within 2 cm of the periphery of the ulcer, and remain in a suprafascial location. Perforating veins were defined as vessels that penetrated the fascia and were associated with a deep vein. Both perforating veins and superficial veins were evaluated for competence, and their respective internal diameters were measured. RESULTS Of the 95 extremities studied with venous ulcers, 46 (48%) occurred on the tight leg and 49 (52%) on the left leg. The overall distribution of incompetence in the superficial, deep, and perforating systems is shown in Table I. Sixty three (66.3%) had multisystem incompetence (S & P + S & D + P & D + S & P & D), whereas single-system incompetence (S + P + D) was seen in only 26 (27.3%) of

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Table I. Distribution of incompetence in the superficial, deep, and perforating systems in 95 extremities with venous ulcers Location

No. of extremities

Percent

S only P only D only S and P only S and D only P and D only S and P and D No incompetence

16 8 2 18 11 4 30 6

16.8 8.4 2.1 19.0 11.6 4.2 31.6 6.3

Total

95

100.0

S, Superficial system; P, perforating system; D, deep system.

the extremities (S = superficial; P = perforating; D = deep). Specifically, isolated deep incompetence was identified in only two extremities (2.1%). In addition, six extremities (6.3%) showed no evidence of valvular incompetence at the areas evaluated. The breakdown of the specific location and distribution of incompetence in the superficial, deep, and perforating systems is shown in Tables II through V. Seventy-five of the 95 extremities demonstrated superficial incompetence. Eighty-nine percent of these exhibited incompetence of the main trunk and/or branches of the greater saphenous vein below the knee (Table II). In contrast, the main trunk and/or branches of the LSV exhibited incompetence in only 41% of the extremities (Table II, top). Specifically, isolated LSV incompetence was seen in only two extremities (Table II, bottom). If an extremity had superficial vein incompetence it generally occurred below the knee in the distribution of the greater saphenous vein. Forty-seven of the 95 extremities demonstrated deep incompetence, the location and distribution of which primarily involved the CFV and the POP V. Seventy-two percent of the extremities had either the CFV or POP V valve incompetent (Table HI, top). The overall distribution of deep incompetence is shown in the bottom of Table III. Twenty-one percent of the extremities had all three valves incompetent. Isolated POP V valve incompetence was seen in 26% of the extremities, whereas isolated CFV valve incompetence was seen in 23%. Superficial femoral vein valve incompetence, either alone or in addition to CFV and POP V valve incompetence, was seen in only 4%. The total number of incompetent perforating veins visualized is shown in Table IV. A total of 146 incompetent perforating veins was seen in 60 of the 95 ulcerated extremities, with a mean of 2.43

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Table II. Location and distribution o f superficial incompetence No. of extremities

Location AK BK LSV Distribution AK only BK only LSV only AK & BK only AK & LSV only BK & LSV only AK & BK & LSV Total

Table IV. Patterns o f perforating vein incompetence Percent

50 67 31

67.0 89.0 41.0

4 16 2 24 2 7 20 75

5.3 21.0 2.7 32.0 2.7 9.3 27.0 100.0

AK, Greater saphenous vein and branches between inguinal ligament and midpatella,medially;BK, greatersaphenousvein and branches betweenmidpateUaand medialmaleolus,medially;LSV, lesser saphenous vein and branches, posteriorly. Table III. Location and distribution o f deep incompetence Location

Location CFV SFV POP V Distribution CFV only SFV only POP V only CFV & SFV only CFV & POP V only SFV & POP V only CFV & SFV & POP V Total

No. of extremities

Percent

34 12 34

72.0 26.0 72.0

11 1 12 1 12 0 10 47

23.0 2.0 26.0 2.0 26.0 0.0 21.0 100.0

CFV, Common femoral vein; SFV, superficial femoral vein; POP V, politeal vein. incompetent perforating veins per extremity. It is interesting to note that the data indicate that as the extent o f disease increased (i.e., P vs P & D & S), the number o f incompetent perforating veins also increased. Statistically significant differences were shown between P and P & S, as well as P and P & D

& s (p < 0.05). The specific distribution o f perforating vein incompetence is shown in Table V and follows the zone system previously described.~° Most incompetent perforating veins were located in zones 6, 7, and 8 (78%), with zone 6 exhibiting more than any other zone (34%). This distribution coincides with previously published descriptions. 1 Evaluation o f the ulcer bed for perforating veins and superficial vessels was even more enlightening.

Distribution

No. of extremities

No. ICP

Mean (ICP/extremity)

P P&D P&S P&D &S Total

8 4 18 30 60

10 6 47 83 146

1.25 1.50 2.60 2.80 2.43

P, Perforating vein incompetenceonly; P & D, perforating vein and deep vein incompetenceonly; P & S, perforating vein and superficialvein incompetenceonly; P & D & S, incompetenceof all three systems; ICP, incompetent perforating veins. Twenty-seven percent o f the ulcers had evidence o f either a competent or incompetent perforating vein, either alone or in combination, with a superficial vein in the ulcer bed, (Table VI). However, 46% o f the 91 ulcers evaluated showed no evidence o f a perforating vein or superficial vein or both in the ulcer bed or within 2 cm o f the periphery o f the ulcer. DISCUSSION The relative contribution o f the superficial, deep, and perforating systems to the development o f the venous stasis syndrome, and ultimately ulcer formation, has been an area o f intense study by general and vascular surgeons for years. Hampered by the inherent limitations o f the various noninvasive testing modalities, only a limited understanding o f the pathophysiology o f the component parts o f the venous system could be ascertained. Since the first application o f duplex imaging to the peripheral venous system, knowledge concerning the true incidence, natural history, long-term consequences, and results o f medical and surgical intervention o f both acute and chronic venous disease has been ever increasing. 1~.13 Clearly the idea o f a "postphiebiric syndrome" as the cause o f all venous ulcers is being questioned. Multiple reports have shown that generally, only 35% to 45% o f patients with venous insufficiency or ulceration or both have evidence o f a past thrombotic episode, as determined by history or noninvasive testing. 6"14 In the present study 33% o f the extremities studied had a history o f superficial phlebitis or deep vein thromboses and duplex evidence in only 44%. It is apparent that additional factors must be in operation. Venous valvular function was usually thought o f as contributing the most to the overall function o f normal venous physiology. In recent years with the aid o f better noninvasive technology other compo-

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Distribution of incompetence in venous ulceration 809

Table VI. Ulcer bed evaluation

Table V. Distribution of perforating vein incompetence Zone *

No. of incompetent perforators

Percent

1

0

0

2 3 4 5 6 7 8 9

2 0 1 18 50 28 37 10

2.0 0 1.0 12.0 34.0 19.0 25.0 7.0

Total

146

100.0

Mean of 2.43 IC perforating veins/leg (range 1-8). *See text for complete description of zones.

nents of the venous system can now be studied and their relationship to the disease process more dearly understood? s'16 The role of resting and ambulatory venom obstruction, calf muscle pump function, lymphatic function, and arteriovenom connections all demand consideration along with the status of the valxatlar system to adequately evaluate each patient. Only then can appropriate medical or surgical therapy be properly chosen. In the current study we chose to examine only the valvular function of the lower extremity venom system in extremities with current venom stasis ulceration. By use of duplex imaging we had the added ability to evaluate the status of the perforating system as well as the deep and superficial systems. This allowed for a more detailed description of the location and distribution of the valvular status of all three systems and is worthy of detailed analysis. Over one half the extremities examined had at least two of the three systems affected, whereas more than 30% had all three systems exhibiting at least one area of incompetence (Table I). Almost 17% of the ulcerated extremities had only superficial incompetence, a condition generally believed not to lead to ulcer formation. If we look at the subset of patients with only superficial incompetence and superficial and perforating incompetence (Table I), as many as 36% of the extremities could have their primary problem corrected with only a superficial vein stripping of the affected areas, either alone or in combination with isolated incompetent perforating vein ligation. In contrast, only 2% of the extremities had isolated deep vein incompetence, and most deep vein incompetence (54%) was associated with superficial incompetence, perforating incompetence, or both. Clearly, it can be seen why investigators who

Vessels visualized

No. of extremities

Percent

Perforating veins only SV only Perforating veins & SV None

14 25 11 41

15.0 28.0 12.0 45.0

Total

91

100.0

SV, superficial veins.

extensivelyuse valvuloplasty and vein valve transplantation in combination with superficial stripping and perforating vein ligation (when appropriate), have improved results in ulcer healing.17 Many authors use vein valve tramplantation and valvuloplasty without regard to the status of the superficial or perforating system or both, and this may be one explanation for less than optimum surgical outcomes. If we look at the distribution of superficial incompetence, (75/95 extremities) we see that most incompetent segments were located below the knee in the distribution of the greater saphenous vein (Table II). Similarly, if we look at the deep distribution of incompetence (47/95 extremities) we see that the POP V was incompetent, either alone or in combination with the SFV or CFV almost 75% of the time (Table III). This confirms the observations of previous reports and demonstrates the importance of the distal venom competence in normal venom function, s'ls19 It must be stressed, however, that the deep system was shown to be incompetent in only half (47/95) of the extremities studied, and isolated POP V incompetence was demonstrated in only two extremities. Complete preoperative evaluation is essential to effectively determine the extent of valvular incompetence and the systems affected. Routine use of one standard operation to treat all venom ulcers is clearly the wrong approach, and each patient must be individually assessed and appropriate therapy carefully chosen. As can be seen in Table V, most incompetent perforating veins were located in zone 6. As stated above, there appeared to be a trend of an increasing number of incompetent perforating veins with an increasing number of systems exhibiting incompetence (Table IV). Sixty of the 95 extremities studied had one or more incompetent perforating veins, eight of which demonstrated only perforating vein incompetence, (no superficial or deep incompetence). This further supports the importance of perforating vein incompetence in the genesis of venom ulcers and demonstrates its association with deep and superficial system pathology.

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Of considerable importance was the examination of the ulcer bed itself. The classic teaching is that each venous ulcer has an associated incompetent perforating vein "feeding it," and that surgical ligation of this vessel is essential to maximize ulcer healing. 1'2° We have demonstrated that nearly half the ulcers exhibited no evidence of any venous disease in or within 2 cm of the ulcer periphery. In 11 of these patients we had the oppommity to verify duplex findings in the ulcer bed with surgical observation during Rob procedure (posterior subfascial ligation of perforating veins via a stocking seam incision). In the extremities that demonstrated no duplex evidence of vessels in the ulcer bed, observation during surgical dissection identified several large sclerotic perforating veins with occluded lumens. Apparently the ulcer did contain an incompetent perforating vein at one time, but the vessel had since thrombosed and become chronically occluded. In any event, simply ligating the "perforating vein feeding the venous ulcer" would not be the appropriate surgical intervention in most patients. Although duplex imaging is highly sensitive in detecting anatomic and functional abnormalities, both obstructive and valvular, as well as arteriovenous connections, it is unable to comment on possible defects of the calf muscle pump. In addition, most instruments currently lack the imaging depth to discover abnormalities in the proximal iliac system and vena cava. In particular, distinguishing between "resting" and "ambulatory" obstruction is impossible without invasive techniques. With this in mind, comment must be made concerning the six extremities that demonstrated no evidence of valvular incompetence. These patients may have had incompetence of the calf veins or deep femoral vein, both areas not evaluated in the current study. We agree with the statements of other authors concerning the importance of these vessels, in particular the posterior tibial veins, and have added their evaluation to our current protocol) 8'~9 Equally as important, possible venous obstruction was only evaluated at the CFV level in the resting state. Although no patient demonstrated evidence of proximal obstruction by duplex imaging, a physiologic test was not done, and therefore possible ambulatory venous hypertension could not be ruled out. Similarly, no comment was made on possible calf muscle pump function. In the future we support the need for complete venous evaluation including a modality such as duplex imaging to characterize the multiple isolated venous abnormalities as well as a modality to

quantitate the overall degree of venous insufficiency contributed by each specific site. Duplex imaging is a highly accurate and sensitive modality in the study of chronic venous insufficiency and is complementary to other noninvasive modalities that comment on the overall venous physiology, including calf muscle pump function and possible obstructive components. Because of this we believe duplex imaging will shed light on a previously poorly understood and chronic disease, ultimately leading to better patient care. REFERENCES

1. Linton RR. The communicatingveins of the lower leg and the operative technic for their ligation. Ann Surg 1938;107:58293. 2. Wilkinson GE, Maclaren IF. Long-term review of procedures for venous perforator insufficiency. Surg Gynecol Obstet 1986;163:117-20. 3. Burnand KG, O'Donnell TF, Thomas ML, Browse NL. The relative importance of incompetent communication veins in the production of varicose veins and venous ulcers. Surgery, 1977;82:9-14. 4. Hoare MC, Nicolaides AN, Miles CR, et al. The role of primary varicose veins in venous ulceration. Surgery 1982; 92:450-3. 5. Shull KC, Nicolaides AN, Fernandes E, Fernandes J, et al. Significance of popliteal reflux in relation to ambulatory venous pressure and ulceration. Arch Surg 1979;114: 1304-6. 6. Raju S, Fredericks R. Valve reconstruction procedures for nonobstructive venous insufficiency: rationale, techniques, and results in 107 procedures with two-to eight-year followup. J VASC SUltG 1988;7:301-10. 7. Rosfors S. Venous photoplethysmography: relationship between transducer position and regional distribution of venous insufficiency. J VAsc SURG 1990;11:436-40. 8. Nicolaides AN, Fernandes E, Fernandes J, Zimmerman H. Doppler ultrasound in the investigation of venous insufficiency. In: Nicolaides AN, Yao JST, eds. Investigation of vascular disorders, 1st ed. New York: Churchill Livingstone, 1981:478-87. 9. Hanrahan LM, Araki CT, Fisher JB, et al. Evaluation of the perforating veins of the lower extremity using high resolution duplex imaging. J Cardiovasc Surg 1991;32:87. 10. Karkow WS, RuoffBA, Cranley 11. B-mode venous imaging. In: Kempczinski RF, Yao IST, eds. Practical noninvasive vascular diagnosis. 1987, Chicago: Year Book Medical Publishers, 1987: 464-85. 11. O'DonneU TF, Burnand KG, Clemenson G, Thomas ML, Browse NL. Doppler examination vs clinical and phlebographic detection of the location of incompetent perforating veins. Arch Surg 1977;112:31-5. 12. Strandness DE. Potential impact of duplex scanning for venous thrombosis. The leading edge in diagnostic ultrasound. May 7-9, 1987 (abstr). 13. Szendro G, Nicolaides AN, Zukowski AJ, et al. Duplex scanning in the assessment of deep venous incompetence. J VASCSURG 1986;4:237-42. 14. Train JS, Schanzer H, Peirce EC, Dan SJ, Mitt-), HA. Radiological evaluation of the chronic venous stasis syndrome. JAMA 1987;258:941-4.

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15. Cristopoulos DG, Nicolaides AN, Szendro G, Irvine AT, Mui-lan B, Eastcott HHG. Air-plethysmography and the effect of elastic compression on venous hemodynamics of the leg. J VASe SURG 1987;5:148-59. 16. Cristopoulos D, Nicolaides AN. Noninvasive diagnosis and quantitation of popliteal reflux in the swollen and ulcerated leg, J Cardiovasc Surg 1988;29:535-9. 17. Kismer RL. In discussion: Raju S, Fredericks R. Valve reconstruction procedures for nonobstructive venous insufficiency: rationale, techniques, and results in 107 procedures with two- to eight-year follow-up. J VASC SURG 1988;7:301-10.

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18. Gooley NA, Sumner DS. Relationship of venous reflux to the site of venous valvular incompetence: implications for venous reconstructive surgery. J VASCSUV,G 1988;7:50-9. 19. Moore JM, Himmel PD, Sumner DS. Distribution of venous valvular incompetence in patients with the postphlebitic syndrome. J VASCSURG 1986;3:49-57. 20. Linton RR. The post-thrombotic ulceration of the lower extremity; its etiology and surgical treatment. Ann Surg 1953;138:415-32. Submitted Oct. 11, 1990; accepted Jan. 22, 1991.

DISCUSSION Dr. Michael H u m e (Boston, Mass.). We are entering a new era with duplex ultrasonography as part of the evaluation of chronic venous insufficiency. Applied here, in the evaluation of management of ulcers, we have extremely interesting information. Remember that before the application o f duplex ultrasonography we had photoplethysmography, some other tests, and quite invasive procedures such as retrograde phlebography. But here we have a noninvasive technique that is tedious and time consuming, but it gives us a great deal of information about the segments that are involved. Techniques are bound to change, because there is even more sophisticated ultrasound equipment with color Doppler that shortens the time of the examination radically. However, ! think that when all this type of information is evaluated in other centers we are going to find that the patterns revealed, like the patterns that were presented to us today, show that no one operation to correct the valvular insufficiency is going to be right for every patient who has an ulcer. The pattern least often found is isolated deep vein insufficiency. It does not come as a surprise that there are few patients for whom an operation limited to the deep vein, perhaps the transplantation of a valve, would be effective. Faced with so many patterns of venous insufficiency one has to concur with the authors that individual physiologic testing must precede the selection of an operation designed to control venous insufficiency. The evidence from insonating the ulcer bed directly may come as a surprise to some. However, those who practice (as we do) deep excision of scar and ulcer will probably concur that a big perforating vein does not lie under every venous ulcer. Tourniquet hemostasis is strongly to be recommended when that operation is done. This report confirms some long-held perceptions we have about controlling venous insufficiency. When a properly selective operation is done for venous insufficiency, a demonstrated physiologic abnormality should be corrected. The information that we got today gives us a way to measure insufficiency and a good guide for specific therapy.

Dr. R. Zwolak (Hanover, N.H.). At this year's meeting of the Society for Vascular Technology, Dr. Kirk Beach from the University of Washington, presented recent work on venous valvular incompetence. He concluded that the determination of venous valvular incompetence depended substantially on the mechanism used to induce reversed venous flow. For instance, when reflux was induced by manual calf compressions, a wide variation in outcome occurred depending on the inherent strength and vigor of the person performing the compressions. Substantial variation in the determination o f valvular incompetence was also noted when a pneumatically inflated thigh cuff was compared to manual compression as the mechanism to induce reflux. My question to the authors, therefore, is whether they noted a variation in reflux determination related to the variety of methods they used to induce reversal of venous flow, and if so, what effect did that finding have on the outcome of the study? Dr. R o b e r t W . H o p k i n s (Providence, R.I.). Just how much technician time does it take? I assume you do not turn it over routinely to the technician and say "go do a valve study." H o w much physician time does it take in addition to technician time? Dr. L.M. Hanrahan. I thank Drs. Hume, Zwolak, and Hopkins for their comments and questions. Dr. Hopkins in regard to your question on the amount of technician time it takes to complete a study, there is a significant learning curve with any duplex testing modality. Usually 3 to 6 months is needed for the technician to fully learn the technique used to work-up chronic venous insufficiency. A fully trained technician can complete a unilateral evaluation of the superficial, deep, and perforating systems, including the ulcer bed, in about 30 to 45 minutes. We regularly study both, so an overall examination can take up to one hour. Dr. Hume, in regard to your question as to if a physiologic abnormality can be surgically corrected with a properly selected operation and if we can detect

812

Hanrahan et al.

a postoperative change, I would like to give the following reply. Historically, ambulatory venouss pressures have been the gold standard used to measure the preoperative and postoperative physiologic changes in the venous system resulting from a particular operation. There is some question now as to the validity of those readings. Multiple reports in the literature demonstrate that even with postoperative ulcer healing, specifically in regard to vein valve transplantation, the ambulatory venouss pressures are unchanged or worse. This can be the case even though the patient is subjectively and/or clinically improved. Our general feeling is that a more physiologic test that comments on the entire venouss physiology of the leg is more appropriate. We have been investigating the use of the air plethysmograph as developed by Dr. Nicolaides' group, in conjunction with duplex imaging. This appears to be a more reproducible and reliable modality, and we plan to use it to follow our patients.

Journal of VASCULAR SURGERY

Dr. Zwolak, in regard to your question about different techniques used to determine valvular competence, let me start by saying that we most definitely see differences. In each patient we exploit all of the three previously mentioned techniques in an attempt to elicit reflux. Proximal and distal manual compression are very effective when evaluating the popliteal vein and more importantly the perforating veins. In contrast, the common femoral vein valve and the saphenofemoral junction are better evaluated by having the patient blow up a rubber examination glove. This is much easier for the patient than a classic Valsalva maneuver. We have not attempted to study in depth the various techniques mentioned, although I know Strandness' group has demonstrated that there is some difference in the quantitation of reflux. For our purposes, if we could demonstrate gross reflux by any of the three techniques, then we qualified the valve as incompetent. If we exploited all the techniques and the valve still appeared normal, we qualified it as competent.