Hemodynamic and clinical improvement after superficial vein ablation in primary combined venous insufficiency with ulceration

Hemodynamic and clinical improvement after superficial vein ablation in primary combined venous insufficiency with ulceration F r a n k T. P a d b e r g , Jr., M D , P e t e r J. Pappas, M D , C l i f f o r d T. Araki, P h D , T h o m a s L. Back, MS, and R o b e r t W. H o b s o n I I , M D ,

Newark and East Orange, N.J. Purpose: This study was undertaken to determine the degree of clinical and hemodynamic improvement after surgical ablation of incompetent superficial and perforator veins in limbs with combined deep and superficial venous incompetence manifested by chronic dermal ulceration. Methods:Eleven limbs in 10 patients with class 5 or 6 venous insufficiency (ulceration) were assessed by CEAP (clinical, etiologic, anatomic, pathophysiologic) clinical scores, air plethysmography, color duplex ultrasonography, and phlebography (both ascending and descending). Surgical ablation of superficial and perforating veins was performed, followed by repeat clinical, air plethysmographic, and color duplex ultrasonographic examinations. Results: All 11 limbs had combined deep and superficial vein reflux on the preoperative color duplex ultrasound scan. Clinical symptom scores decreased from 10 to 1.4 after operation. Postoperative air plethysmography demonstrated significant reduction in reflux as measured by the mean venous filling index, which decreased from 12 + 5 ml/sec to 2.7 _+1 ml/sec after surgery. Calf pump function was also significantly improved, with a mean ejection fraction that increased from 43% + 11 to 59% + 13 and mean residual volume fraction that decreased from 56% + 15 to 33% + 16. Each of these measures was significantly different from the preoperative value (p < 0.05). Similar improvement characterized subgroups of limbs with three or more incompetent deep segments (n = 6) or popliteal segment incompetence (n = 6). Conclusions: Superficial and perforating vein incompetence accounts for a substantial and correctable component of venous insufficiency in limbs with combined deep and superficial vein reflux and venous ulceration. These data indicate that surgical correction of this component significantly improves clinical symptoms and venous hemodynamics. Superficial and perforator ablation is an appropriate initial step in the management of combined deep and superficial venous incompetence. (J Vase Surg 1996;24:711-8.)

The value of superficial venous ablation in the management o f chronic venous insufficiency remains controversial. Many surgeons have assumed that the predominant hemodynamic abnormality is related to the deep venous system, suggesting that this component must be corrected to improve venous function. The role of superficial and perforator ablation as

From the Section of Vascular Surgery, Universityof Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark; and the VeteransAffairsMedical Center, East Orange. Presented at the Eighth Annual Meeting of the AmericanVenous Forum, San Diego, Calif., Feb. 22-24, 1996. Reprint requests: Dr. F. Padberg, Jr., Department of Surgery (112), VA Medical Center, 385 Tremont Ave., East Orange, NJ 07018-1095. 24/6/76488

opposed to deep venous reconstruction has not been studied thoroughly. Shami et al.1 reported favorable outcome with saphenous ligation and excision in patients who had ulceration (47% of w h o m also had deep venous insufficiency). These authors also hypothesized that large-volume reflux was a significant factor; however, they characterized their series with duplex examinations rather than hemodynamic measurements. Christopolous et al.2 correlated an increasing volume o f reflux with increasing severity o f symptoms using air plethysmography (APG). Although APG assessment o f the effects o f saphenous ablation has been described, 3'4 a specific evaluation of the ulcerated limb has not. Schanzer and Pierce 5 recognized the importance o f the perforator veins and emphasized concomitant 711

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saphenous vein excision. Masuda and Kistner6 and other advocates of deep vein valvular reconstruction 7,8 have also recognized the importance of the superficial and perforator system. A comprehensive operative procedure for management of severe venous insufficiency is recommended by these authors. The objective of this study was to determine the degree of hemodynamic improvement after surgical ablation of the incompetent superficial and perforating veins without the addition of a deep venous reconstructive procedure. Primary venous insufficiency was assessed in 11 limbs that each had recurrent dermal ulceration. All limbs had clinically evident superficial venous disease and varying degrees of deep valvular insufficiency as determined by clinical, color duplex, and APG examinations. METHOD

Eleven limbs in 10 male patients who had primary venous insufficiency were studied. The mean age was 66 years (range, 46 to 72 years) in patients who were evaluated for ulceration at the distal calf and ankle. The presence of greater saphenous varices and the incompetence of the superficial venous system was established at the initial clinical examination, which was augmented with a bedside continuous-wave Doppler examination. Open ulcers were treated with compression dressings or paste boots until healing was achieved. The deep venous system was characterized by color duplex ultrasound, APG, and phlebographic examinations, which were conducted a mean of 1.2 months before operation. Secondary (postthrombotic, posttraumatic) venous disease was excluded by history, color duplex scans, and phlebographic examinations. Arterial insufficiency was excluded by the presence of palpable pedal pulses or an ankle-brachial index greater than 0.8. Limbs were characterized with the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification described in the most recent update of reporting standards in venous disease. 9 All limbs were clinical class 5 or 6. All had primary chronic venous insufficiency, and none had previous deep vein thrombosis as determined by history, color duplex scans, or phlebographic examinations. All 11 limbs had components of deep, superficial, and perforator incompetence. Venous obstruction was excluded by both noninvasive and phlcbographic examinations. The pathophysiologic mechanism in each of the 11 limbs was severe primary reflux. Thus, using CEAP shorthand, these patients were classified as Cs,6EpAs,D,pPI~. Clinical symptom scores were assigned on a 0-to-2

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scale (0 was asymptomatic and 2 was severe) for the nine items listed in Table I, A; the scores were then totaled to provide a summary score for each limb. Preoperative clinical symptom scores ranged from 8 to 12, with a mean of 10 + 2 (Table I, C). APG examinations were conducted as described by Christopolous et al} and Back et al.10 (APG 1000C; ACI Medical Inc, Sun Valley, Calif.). Reflux into the calf was determined by measurement of the venous filling index (VFI). VFI is a measure of the average rate of increase in calf volume that occurs when the subject changes from a supine position with the leg elevated to a standing position. The venous system was tested for obstruction by measurement of the outflow fraction (OF), which is measured in the supine position with a thighoccluding cuffplaced on the elevated extremity; OF represents the percentage of venous volume drained from the calf within 1 second of release of the occluding cuff. Calf pump function was determined by measurement of the ejection fraction (EF) and the residual volume fraction (RVF). EF is a measure of the percentage of venous volume that is removed from the calf with a single tiptoe maneuver. RVF is a measure of the percentage of venous volume remaining in the calf after a series of 10 tiptoe maneuvers. Arterial inflow to the calf was measured under resting conditions in the supine position and is defined as the average increase in calf volume over time immediately after inflation of a thigh cuffto 70 mm Hg. These values were obtained at preoperative and postoperative examinations. Color duplex ultrasound examinations were performed to evaluate the venous system for the pattern of valvular reflux and location of perforating veins (Quantum 2000, Siemens Quantum Inc, Issaquah, Wash.). Examinations were conducted in the reverse Trendelenburg and standing positions using manual compression; the technique previously has been described in detail. H Valvular incompetence was defined as a reversed flow duration greater than 0.5 seconds for each segment except the common femoral vein, where reverse flow longer than 1.5 seconds was considered evidence of reflux. At the initial examination, and again at each follow-up interval, systematic interrogation of the common femoral, superficial femoral, profunda femoris, popliteal, posterior tibial, peroneal, and anterior tibial veins was conducted; greater and lesser saphenous systems and perforating veins were also interrogated. For purposes of comparison, segments in the thigh were deemed "proximal," and segments in the popliteal or crural distribution were "distal." Perforator veins

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Table I, A. CEAP summary clinical symptom scores (n = 11)

Before surgery After surgery

Pain

Edema

Pigment

Venous claudication

LDS

Ulcer >3 cm

Ulcer >3 mo

Ulcer recur

No. of ulcers 0,1,2+

11 2

15 1

15 8

1 0

i3 6

14 0

19 0

12 0

12 0

Total CEAP clinical symptom scores are given for 11 limbs with superficial and perforator ablation. Individual scores range from 0 to 2, for a maximum of 22 in each category. Postoperative scores reflect no recurrent ulceration. LDS, lipodermatosclerosis.

Table I, B. Total reflux components identified by duplex

Before surgery After surgery p

Table I, C. Mean clinical symptom score CEAP clinical symptom score

Deep segments incompetent

Perforating veins

24 21 0.075

i9 2 --

Before surgery After surgery p

10.1 ± 1.6 1.45 ± 1.0 0.0001

CEAP scores were assigned in nine categories, for a maximum of 18 in each limb. Scores are expressed as mean ± SD.

Reflux components in 11 limbs have been totaled here.

were identified by bidirectional flow on deep vein compression and the communicating lumen imaged from the superficial to the deep vein. n The sites of incompetent perforating veins were marked before surgery. Ascending phlebographic scans were performed on a fluoroscopic tilt table with injection of contrast medium into a dorsal foot vein of the dependent, non-weight-bearing limb. Visualization of the deep system was accomplished with the application of an ankle tourniquet. Patients who had evidence of obstructive or previous thrombotic disease were excluded from further evaluation for this study. Descending phlebographic examinations were performed on the same table with common femoral vein puncture and valvular competency assessed with Valsalva's maneuver. Grading was as reported by Kistner. 6 Four of 11 limbs had deep vein reflux below the knee (grade 3 or 4). Surgical correction of the superficial venous system was performed in the 11 limbs with standard techniques. The procedure consisted of division and flush ligation at the saphenofemoral or saphenopopliteal junction, followed by stripping from groin to midcalf with ligation of tributary branches. One lesser saphenous vein was ligated at its origin at the same operation. All 11 limbs had subfascial ligation of one to five perforating veins. Subfascial ligation of perforating veins was initially accomplished by direct incision and later by an endoscopic approach. Patients returned I month after surgery and again at annual intervals for clinical, APG, and color duplex examinations. Statistical analyses were performed with the paired t test and the signed rank test with

significance assigned when p was 0.05 or lower. Values are expressed as mean ± the standard deviation. RESULTS Clinical improvement was manifested by a reduction in symptoms and the absence of recurrent ulceration in all 11 limbs. All patients were ambulatory and had a mean follow-up of 16.4 months. Compression hose have not been worn on six of the 11 limbs; 30-tort to 40-torr hose have been regularly worn on the remaining five limbs. The mean clinical symptom scores after surgery decreased significantly (p< 0.0001) from 10.1 ± 2 to 1.45 ± 1, as summarized in Table I, C. A clinical outcome grade relative to preoperative status was also assigned using the -3 (markedly worse) to +3 (asymptomatic) scale recommended in the reporting standards9; the mean clinical outcome grade was +2.2 at the last follow-up examination for these 11 limbs. Color duplex examinations before surgery verified incompetence of the greater saphenous vein at its origin and throughout the thigh and proximal calf in each of the 11 limbs; the postoperative color duplex scans confirmed the absence of saphenofemoral incompetence in each limb. Perforator incompetence was identified before surgery in 11 limbs. Although all perforating veins that were identified by color duplex scans were ligated, an incompetent perforating vein was identified by color duplex evaluation in two patients on subsequent postoperative examinations. One that was incompletely ligated thrombosed after 5 months; another, identified in unstable sldn just posterior to the malleolus, was left in situ. Color duplex examination identified deep valvular

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Reflux 12 10 o

8

E

6

LL

>

Venous Filling Index

4 2 0

I

I

I

I

I

Calf Pump Function 80

Ejection Fraction

70 60 50 % 40

Residual Volume Fraction

30 20 10 0

I

I

I

Pre-Op

Post-Op

1Year (n=11)

I

18Mon (n=6)

2Year In=5)

Duration of Observation Fig. 1. Hemodynamic changes before and after surgical intervention are plotted over 2-year follow-up. VFI reflects venous reflux; ejection fraction and residual volume fraction reflect calf pump function. Values are plotted as mean + SD; n = number of limbs; *p < 0.05 comparing postoperative values with preoperative mean. incompetence in all 11 limbs, with a total of 24 incompetent segments. Six limbs had three incompetent deep segments, one had two, and four had a single incompetent deep segment. The distribution was predominantly proximal (18 o f 24 segments), but six limbs had distal incompetent segments. Because no tibial vein incompetence was found, the distal segments were all popliteal. After surgery, a total o f 21 incompetent segments were identified. No evidence o f persisting deep vein reflux was observed after surgery in three limbs; one limb had had three incompetent segments, and two had had isolated common femoral and popliteal segment incompe-

tence. Six limbs were unchanged from the preoperative findings. Two limbs worsened with the addition o f another deep segment. Interestingly, these two patients also had grade 3 to grade 4 reflux on descending phlebographic evaluation. Twenty-four dccp segments were identified before surgery, and 21 were prcscnt aftcr surgery (Table I, B). The initial (preoperative) APG examinations demonstrated reflux (VFI, 12 + 5 ml/sec) and calf pump dysfunction (EF, 43% + 11; RVF, 56% + 15). At the first postoperative examination after ablation of superficial and perforating veins, VFI, EF, and RVF were significantly improved, as noted in Table II. On

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Table II, A. Hemodynamic measurements before and after surgery

Preoperative exam First postoperative exam Last postoperative exam

n

OF (%)

VII (ml/min)

W (ml)

EF (%)

RVF (%)

Mean follow-up (too)

11 11 11

66 + 11 64 + 9 53 + 12"

12 _+ 5 3.4 _+2* 2.7 _+ 1"

234 + 58 175 _+43* 145 _+ 36*

43 _+ 11 55 -+ 16" 59 -+ 13"

56 -+ 15 41 + 22* 33 + 16"

-1 4 16

Values expressed as m e a n + SD. *p < 0.05 w h e n compared with respective preoperative value.

Table II, B. Comparative diagnosis of deep segment disease--descending phlebographic examinations (grade 3 or 4)

Preoperative exam First postoperative exam Last postoperative exam

n

OF (%)

VFI (ml/min)

W (ml)

EF (%)

RVF (%)

Mean follow-up (too)

4 4 4

62 + 17 61 + 6 48 + 13"

13 + 7 4.2 + 31" 3.0 + 3:~

248 + 85 189 + 55* 150 + 34§

39 + 10 44 + 19 51 + 14

59 + 11 52 + 27 45 + 15[1

4 16

Values expressed as mean + SD. *p < 0.05 when compared with respective preoperative value.

tp = o.o52. ~;p = 0.065.

§p = 0.07. I]P = 0.10.

subsequent examinations, VFI decreased further, EF increased, and RVF decreased (Table II). A further trend toward normal values was observed in subsequent follow-up examinations (Fig. 1). Arterial inflow was 100 + 37 ml/min before operation and 88 + 41 ml/min after (p = 0.38 ). Arterial flow was not significantly different after ablation of superficial and perforating veins. Three subgroups ofAPG hemodynamic data were analyzed to evaluate whether greater severity of deep venous insufficiency would decrease the benefits of the superficial procedure. The three subgroups included (1) four patients who had grade 3 or 4 descending phlebographic reflux; (2) six patients who had three or more incompetent deep segments on color duplex examination; and (3) six patients who had distal (i.e., popliteal) incompetent segments on color duplex examination. Significant improvement in hemodynamic function was observed (Table II). The mean VFI decreased from 13 + 7 ml/sec to 3 + 2 ml/sec in limbs that had grade 3 or 4 descending phlebograms. Both reflux (VFI) and calf pump function (EF and RVF) improved significantly in limbs that had three incompetent segments and in limbs that had distal incompetent segments. The mean VFI returned to normal in limbs that had proximal segment incompetence. In each subgroup, a continued trend toward normal values was observed in subsequent follow-up.

DISCUSSION

Clinical improvement in these 11 limbs was significant when assessed with summary symptom scores (Table I). Although pigmentation remained in most limbs, the patients' perception of improvement was noted. As might be expected, deep dermal scarring was largely unchanged. Pruritus was notably absent. No ulcers have recurred, despite noncompliance with compression stockings in six patients. Hemodynamic improvement was observed after surgical treatment in patients who had venous ulceration as a result of combined primary deep and superficial venous insufficiency. The APG parameters for reflux and calf pump function returned toward normal (Fig. 1) despite little change in the deep system. Color duplex examination continued to show deep-segment reflux in the majority of limbs; however, it appeared to be abolished completely in three limbs. Walsh et al. 13 also reported abolition of deep venous insufficiency in several limbs after saphenectomy alone. The hemodynamic effects of saphenOus ablation have been reviewed by several authors. Usually, however, the sample included a mixture of limbs that had less severe clinical symptoms and limbs that had more severe chronic venous insufficiency. 4,1416Shami et al. 1 reported duplex findings in patients who had ulcers, but were unsure of the significance of the perforator veins. Masuda and Kistner 6 and other advocates of

•

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Table I I , C. Comparative diagnosis o f deep segment disease--duplex scans: three deep segments

Preoperative scan First postoperative scan Last postoperative scan

n

OF (%)

VFI (ml/min)

VV (ml)

EF (%)

RVF (%)

Mean follow-up (mo)

6 6 6

65 + 16 61 + 7 45+9*

13 + 7 4.8 + 2* 3.7+1"

229 + 80 i81 _+46* 136+30"

41 + 9 48 + 16 57+15"

57 + 12 54 + 2I 40+17"

4 21

Values expressed as mean + SD. *p < 0.05 when comparedwith respective preoperative value.

Table I I , D. Comparative diagnosis of deep segment disease--duplex scans: proximal vs. distal segment incompetence n Proximal Preoperative exam First postoperative exam Last postoperative exam Distal Preoperative exam First postoperative exam Last postoperative exam

OF

VFI

VV

EF

RVF

Mean follow-up

(%)

(ml/min)

(ml)

(%)

(%)

(too)

5 5 5

69 + 6 66 +_9 60 + 2*

10 + 3 1.7 +_l* 1.8 + l*

222 + 47 151 + 37* 135 + 31"

40 + 10 53 + 22 54 + 16J"

64 + 10 42 + 28* 36 + 20*

6 10

6 6 6

63 + 15 63 + 10 48 _+15"

I3 + 6 4.8 + 2* 3.6 + 1"

244 + 69 196 + 38* 152 + 42*

46 + 12 57 + 10" 63 + 10"

50 + 17 40 + 175 30 + 14"

3 18

Values expressed as mean _+SD. *p < 0.05 when compared with respective preoperative value.

tp = 0.07. ~p = 0.10.

deep venous reconstruction 7'8 have long recognized the importance o f superficial and perforating vein incompetence and incorporated the ablation o f both in a comprehensive operative procedure for management o f severe deep venous valvular insufficiency. Advanced age is a c o m m o n feature in reports on superficial venous surgery in limbs with ulceration. The mean age of patients in this study was 66 years; for Shami et al. 1 it was 61 years, and for Hoare ct al. 1~ it was 58 years. This suggests that prolonged exposure to the hemodynamic abnormalities may be a factor in the development of increasing severity o f symptoms. The magnitude of reflux is a factor as well. For example, Christopolous et al.2 observed ulceration in 60% o f limbs that had VFI greater than 10 ml/sec, which was the mean preoperative VFI observed in the current study. The role o f perforator incompetence is less clearly defined. Most surgeons continue to believe that deep system incompetence must accompany perforator disease. Ligation o f the perforating veins without concomitant management directed at the deep or superficial systems produced minimal clinical or hemodynamic i m p r o v e m e n t s Because there is no definitive test to evaluate the contribution o f incompetent perforating veins to total venous incompetency,

we have elected to ligate all incompetent perforating veins that are identified by color duplex scans at the time o f superficial venous ablation. Preoperative identification and localization by duplex mapping is a major adjunct to the surgical procedure} 2 Remote incision for endoscopic subfascial ligation reduces periopcrative morbidity rates} s Patients who are referred for management o f venous ulcerative disease have varying degrees o f deep and superficial valvular incompetence. Excellent results have been described with the use of valvular repair or transposition for primary valvular insufficiency.4 Many practitioners, however, have combined surgical treatment of deep and superficial incompetence at the time o f the initial reconstruction. 6-s When treatment was directed at the deep system alone, the altered hemodynamics were, at best, transitory, and the clinical results were less satisfactory. 19 Thus early hemodynamic failure has led to a recommendation that clinical reports on these procedures include a minimum o f 6 to 12 months o f clinical evaluation. 9 Serial physiologic and clinical examinations will determine whether the observed hemodynamic improvement in this group o f patients persists. To date, little deterioration o f the deep valvular incompetence has been observed in the patients in our series• In fact,

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although the data must be considered preliminary, continued hemodynamic improvement was observed for each of the more severe deep venous subgroups through the duration of follow-up. Subgroups that were assumed to have the greatest severity of deep venous incompetence showed significant hemodynamic improvement, which was maintained through the duration of follow-up. Although improvement in the data from the subgroup that demonstrate incompetence on descending phlebographic scans was not as significant when compared with other subgroups, this may be a reflection of the small sample size because the mean values closely resembled those obtained in the whole group at the first postoperative evaluation. The subgroup that had proximal segment incompetence achieved the greatest hemodynamic improvement; this was the only subgroup in which the VFI returned to normal after surgical intervention. The postoperative VFI in the distal incompetence subgroup was also significantly improved, but did not return to normal. Postoperative calf pump function in the distal subgroup, however, did return to normal, an observation that probably reflects the absence of tibial vein incompetence in these limbs. Bradbury et al.20 observed that recurrence of ulceration was strongly correlated with popliteal incompetence after superficial and perforator ablation. Gooley and Sumner 21 have also emphasized the significance of the distal valvular segments. Thus limbs with popliteal incompetence warrant continued close observation. Inconsistency between different assessment methods has confused progress in management of venous insufficiency. Comparative evaluations of clinical findings with color duplex scans, phlebographic examinations, and APG have not correlated well with previously recommended classifications that attempted to categorize the severity of disease. 22-24 Clinical evaluation has focused largely on descriptive findings and has been hampered by the lack of uniform terminology and lack of a universal standard for severity of disease. Recent efforts by committees from the Society for Vascular Surgery, the International Society for Cardiovascular Surgery North American Chapter, and American Venous Forum have helped to standardize reporting of venous pathophysiologic mechanisms, leading us to use the CEAP recommendations of these committees .9 Clinical examination supplemented with handheld continuous-wave Doppler evaluation is sufficient to establish the presence of significant superficial venous incompetence. Color duplex examination, however, is essential for characterization of deep

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717

venous disease. APG testing provides reproducible hemodynamic measurements that can be evaluated noninvasively in serial examinations. 2'3 Multimodal testing consisting of clinical, color duplex, and hemodynamic examinations will be essential for accurate assessment before corrective venous reconstruction is undertaken. 23 Superficial and perforator vein ablation in limbs that have primary combined deep and superficial venous incompetence resulted in significant clinical and hemodynamic improvement. Both reflux and calf pump function were significantly improved as measured by APG. Significant clinical improvement was demonstrated using the CEAP classification system. Although color duplex examination of the deep system did not change significantly, deep valvular incompetence, whether proximal or distal, did not preclude significant hemodynamic improvement. Subsequent examinations show continued improvement in the mean hemodynamic parameters. Thus, for initial surgical management of primary chronic venous insufficiency of any grade, with superficial and deep disease, we recommend superficial and perforator ligation as a preliminary step before considering deep venous reconstruction. REFERENCES 1. Shami SK, Satin S, Cheafle TR, Scurr IH, Smith PDC. Venous ulcers and the superficial venous system. J Vasc Surg 1993;17: 487-90. 2. Christopolous D, Nicolaides AN, Szendro G. Venous reflux: quantitation and correlation with clinical severity of venous disease. Br J Surg 1988;75:352-6. 3. Chtistopolous D, Nicolaides AN, Galloway JMD, Wilkinson A. Objective noninvasive evaluation of venous surgical results. J Vasc Surg 1988;8:683-7. 4. Gillespie DC, Cordts PR, Hartono C, Woodson J, Obi-Tabot E, LaMorte WW, Menzoian JO. The role of air plethysmography in monitoring results of venous surgery. J Vase Surg 1992;I6:674-8. 5. Schanzer H, Pierce ECC II. A rational approach to surgery of the chronic venous stasis syndrome. Ann Surg 1982;i95:25-9. 6. Masuda EM, Kistner RL. Long-term results of venous valve reconstruction: a four- to twenty-one-year follow up. J Vase Surg 1994;19:391-403. 7. Sotturai VS. Surgical correction of recurrent venous ulcer. J Cardiovasc Surg (Torino) 1991;32:104-9. 8. 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 Vase Surg 1988;7:301-10. 9. Porter JM, Moneta GL, International Consensus Committee on Chronic Venous Disease. Reporting standairds in venous disease: an update. J Vasc Surg I995;21:635-45. 10. Back TL, Padberg FT Jr, Araki CT, Thompson PN, Hobson RW II. Limited range of motion is a significant factor in venous ulceration. J Vase Surg 1995;22:519-23. 11. Araki CT, Back TL, Padberg FT Jr, Thompson PN, Duran

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WN, Hobson RW II. Refinementsin the ultrasonic detection of popliteal vein reflux. J Vasc Surg 1993;18:742-8. Hanrahan LM~ Araki CT, Rodriguez AA, Kechejian GJ, LaMorte WW, Menzoian JO. Distribution of valvularincompetence in patients with venous stasis ulceration. J Vase Surg 1991;13:805-12. Walsh JC, Bergan JJ, Beaman S, Carver TP. Femoral venous reflux abolished by greater saphenous stripping.Ann VascSurg 1994;8:566-70. Sethia KK, Darke SG. Long saphenous incompetence as a cause of venous ulcerations. Br J Surg 1984;71:754-5. Hoare MC, Nicolaides AN, Miles CR, Shull K, Jury RP, Needham T, Dudley HAF. The role of primary varicoseveins in venous ulceration. Surgery 1982;92:450-3. Struckman JIL Assessmentofvenous musclepump function by ambulatory calf volume, strain gauge plethysmography after surgical treatment of varicose veins: a prospective study of 21 patients. Surgery 1987;101:347-53. Burnand KG, O'DonnellTF Jr, Thomas ML, Browse NL. The relative importance of incompetent communicating veins in the production of varicose veins and venous ulcers. Surgery 1977;82:9-14. Jugenheimer M, Junginger T. Endoscopic subfascialsectioning of incompetent perforating veins in treatment of primary varicosis. World J Surg 1992;16:971-95.

19. Johnson ND, Queral LA, FlinnWR, Yao JST, Bergan JJ. Late objective assessment of venous valve surgery. Arch Surg 1981;116:1461-6. 20. BradburyAW,Stonebridge PA, CallamMJ, RuckleyCV, Allan PL. Foot volumetry and duplex ultrasonography after saphenous and subfascial perforating vein ligation for recurrent venous ulceration. Br J Surg 1993;80:845-8. 21. Gooley NA, Sumner DS. Relationshipof venous reflux to the site of venous valvularincompetence: implicationsfor venous reconstructive surgery. J Vasc Surg 1988;7:50-9. 22. Iafrati MD, Welch H, O'Donnell TF, Belldn M, Umphrey S, McLaughlin R. Correlation of venous noninvasivetests with the Society for Vascular Surgery/International Society for CardiovascularSurgery clinicalclassificationof chronic venous insufficiency.J Vasc Surg 1994;19:1001-7. 23. van Bemmelen PS, Mattos MA, Hodgson KJ, BarkmeierLD, Ramsey DE, Faught WE, Sumner DS. Does air plethysmography correlate with duplex scanning in patients with chronic venous insufficiency.J Vase Surg 1993;18:796-807. 24. McEnroe CS, O'Donnell TF, Mackey WC. Correlation of clinicalfindingswith venous hemodynamicsin 386 limbs with chronic venous insufficiency.Am J Surg 1988;156:148-52.

Submitted Feb. 28, 1996; accepted July 11, 1996.

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