SCLEROTHERAPY FOR TELANGIECTASIS OF THE LEG: RESULTS OF A FIVE-YEAR FOLLOWUP
 Lucchi M, Bilancini S, Tucci S.
Phlebology 1996; 11:73-75

ABSTRACT AND COMMENTARY BY:
John R. Pfeifer, M.D.
Detroit, Michigan

Dr. Lucchi and associates of Frosinone, Italy under-took a retrospective study of 52 patients who had previous sclerotherapy for spider telangiectasias to determine recurrence after sclerotherapy. All patients were female (mean age 37) and all had undergone sclerotherapy more than five years previously. The type of vein injected was the small, subpapillary plexus vein, 1 mm in diameter or less. Prior to treatment, a detailed map of telangiectasias was made for each leg. At the end of each session, the sites of injection and the sclerosant used were recorded. Patients with saphenous or deep vein insufficiency were not included in the study. The sclerosing agent was chromated glycerin or polidocanol. Compression was carried out for five days using cotton wool rolls held in place with adhesive bandaging. Treatment was given every 15 days. At each followup, the presence of new telangiectasias was noted on a diagram and compared with the previous diagrams.

Forty of 52 patients (77%) demonstrated development of new telangiectasias. A total of 67% were in a different area, and 56% were in the same location poreviously treated. In 24 of 52 patients (46%), telangiectasias occurred both in the originally treated area and in new areas. In 19 of 40 patients (48%), additional telangiectasias were minimal and required little or no treatment.

The authors concluded that sclerotherapy of telangiectasias treats the consequence of this venous disorder without addressing the cause. Thus, recurrence is a frequent problem. Rather than true recurrence, this is regarded as an evolution of the disease. Maintenance treatment is suggested to sustain the results following the initial course of sclerotherapy.

COMMENTARY

The authors are to be commended for this unusual and comprehensive followup of a small group of 52 patients. However, while their injection technique appears to be very comprehensive and effective, they have not addressed the primary cause referred to in this paper - venous hypertension secondary to valve incompetence. Faria and Morales pointed out the high degree of communication between deeper incompetent veins and surface telangiectasias, and this has suggested to us the need for long-term compression therapy. In this study, however, the authors refer only to an initial period of five days. It is my belief that some degree of long-term compression is necessary to retard recurrence of telangiectasias. Although some recurrences are in fact the same vein previously treated, in our experience the majority are new telangiectasias relating to venous hypertension in the lower extremity.

In summary, this is an excellent article displaying an unusual degree of followup. However, I believe that results will improve with long-term compression using pressure-gradient hose. 6122b




NEOVASCULARIZATION IS THE PRINCIPAL CAUSE OF VARICOSE VEIN RECURRENCE: RESULTS OF A RANDOMIZED TRIAL OF STRIPPING THE LONG SAPHENOUS VEIN
 Jones J, Braithwaite BD, Selwyn D, et al.
Eur J Vasc Endovasc Surg 1996; 12:442-45

ABSTRACT AND COMMENTARY BY:
Simon G. Darke, MS, FRCS
Dorset, England

This is one of a number of recent studies utilizing color-coded duplex to investigate varicose veins. It is a prospective, randomized trial of simple saphenofemoral ligation compared with ligation and long saphenous vein stripping. Patients were evaluated for clinical evidence of recurrence and duplex imaging of the groin for reemergence of reflux two years following surgery.

These findings confirm previous work and show an advantage in terms of reduced recurrence in favor of those stripped. Neovascularization (the emergence of new tributaries) to a varying degree was found arising from the femoral vein in just over 50% of all cases and was the major cause of recurrence. Most of these newly formed tributaries were less than 3 mm in diameter and were only of clinical significance if the saphenous vein or an accessory major thigh vein were intact. However, 12 of the total 113 studied had tributaries greater than 3 mm and all of these had clinically apparent recurrent varicose veins.

COMMENTARY

The concept of neovascularization is not new. It was described both by Langenbeck and Perthes at the end of the 19th century. Strangely, the surgical profession has been reluctant to recognize this phenomenon, choosing to ascribe groin recurrences as largely due to technical inadequacies at the time of surgery. However, now there is irrefutable evidence that the hypothesis of our forebearer is, in most instances, correct. The recent study adds further weight to this view. What is interesting and remains unexplained, however, is the apparent idiosyncratic variation as to the degree to which this occurs between individual patients. Apart from removing the long saphenous trunk to minimize its effect as shown here, as yet there is no known means to prevent neovascularization. 6124b




STANDARD STRIPPING VS LONG SAPHENOUS VEIN-SAVING SURGERY FOR PRIMARY VARICOSE VEINS: A PROSPECTIVE, RANDOMIZED STUDY WITH THE PATIENTS AS THEIR OWN CONTROL
 Campanello M, Hammarsten J, Forsberg C, et al.
Phlebology 1996; 11:45-49

EDITORIAL: VARICOSE VEIN SURGERY
 Norgren L.
Phlebology 1996; 43-44

ABSTRACT AND COMMENTARY BY:
C. Vaughan Ruckley, MB, ChM, FRCSE
Professor of Vascular Surgery
Edinburgh, Scotland

The objective of this trial by Campanello, et al. was to compare postoperative discomfort and long-term outcome following "standard" stripping compared with long saphenous vein-saving surgery. Patients were investigated preoperatively by strain-gauge plethysmography, ascending phlebography, and descending phlebography. Those with bilateral varicose veins were chosen. Each patient was his/her own control. One leg was randomized with respect to the first procedure, and the alternative procedure was later performed on the other leg. Saphenofemoral disconnection was performed through a groin incision of at least 10 cm. In the stripping group, the long saphenous vein was stripped from groin to ankle. Incompetent perforators, as detected and located by phlebography, were ligated superficial to the deep fascia through skin incisions 2 to 3 cm in length. Occasionally, if the insufficient perforator was not found extrafascially, the incompetent perforator vein was identified and ligated subfascially through an extended skin incisions. Patients were interviewed and examined by plethysmography and ultrasonography three months after the second procedure and for a mean followup period of four years.

A mean of 1.5 and 1.7 incompetent perforators were ligated in the stripping group and the non-stripping group, respectively. There was no difference between the two groups in the plethysmographic findings at followup. Thirteen of 18 patients (72%) thought there was less subjective discomfort in the postoperative period following long saphenous vein-saving surgery than after stripping (p < 0.01). Ultrasound examination of the preserved long saphenous veins in the high-ligation group showed that the vein in all limbs was patent, compressible, non-sclerotic, and free of intraluminal echoes. Outcome in the vein-saving group showed that 14 (77%) were excellent and three were good. There was one recurrence. Outcome in the stripping group showed that 17 (94%) were good with no recurrence (not significant).

The authors conclude that the long-term results of long saphenous vein-saving surgery are as good as standard stripping provided that incompetent perforators are thoroughly mapped preoperatively and ligated at surgery. They also conclude that long saphenous vein-saving surgery caused less subjective discomfort than the standard stripping and that the saved long saphenous vein can "probably" be used for future arterial reconstruction.

Professor Norgren, in his editorial in the same issue of Phlebology , points out that reports in the literature as to whether the incompetent saphenous vein may be preserved remain conflicting. This suggests that the difference may lie in the way the authors dealt with perforators. He felt that although Campanello, et al. demonstrated that saphenous veins could be preserved, the issue remains controversial.

COMMENTARY

This reviewer found a number of difficulties in interpreting this study. First, the authors stripped the saphenous vein from ankle to groin although their description does not state in which direction. In the United Kingdom, most surgeons have abandoned full-length saphenous vein stripping. It is not surprising that Campanello and his colleagues noted considerably more postoperative discomfort in the stripping group.

The second difficulty concerns the perforator surgery. Most venous surgeons search for perforators below the knee. Campanello, et al. appears to have searched for and ligated perforators on the calf and thigh. If this is the case, the mean of 1.5 to 1.7 incompetent perforators per leg seems an extremely low number. We are left wondering how accurate their ascending and descending phlebography was in detecting perforating veins.

The fact that the authors were able to demonstrate patent saphenous veins on followup does not mean that these veins are suitable for bypass. The suspicion is that varicose veins are structurally damaged. Until we have information on the long-term outcome of bypasses constructed with preserved saphenous veins, it is difficult to know whether the effort is worthwhile. The analysis of the outcome of varicose vein surgery appears to favor the stripping group consistent with the considerable body of evidence that failure to remove the saphenous vein is associated with recurrence. The authors say that the differences are not significant, but with 18 legs in each group, we clearly have a Type 2 statistical error. 6123b




INSUFFISANCE VEINEUSE CHRONIQUES 7 a 10 ANS APRES INTERRUPTION PARTIELLE DE LA VEINE CAVE INFERIEURE PAR CLIP EXOCAVE (Chronic Venous Insufficiency 7 to 10 Years After Partial Vena Cava Interruption with a Clip)
Fontaine M, Bosson JL, Bourgin Y, et al.
J Maladies Vasculaires 1996; 21:153-57

ABSTRACT AND COMMENTARY BY:
J. J. Guex, M.D.
Nice, France

Partial interruption of the inferior vena cava with a venous clip is much less frequently done today than use of vena cava filters. The clips were thought to cause a great number of complications of chronic venous insufficiency in the lower extremities in the past. There are few or perhaps no clinical studies published today which can be relied upon. Therefore, the authors carried out a retrospective study of patients operated upon with comparison to a matching group of patients with deep venous thrombosis appearing contemporaneously.

Forty-five patients were treated with a vena cava clip between 1982 and 1986. On followup, eight had died. The remaining 37 answered a telephone survey, and 29 came to the hospital for a complete examination. A similar evaluation was done for the control patients - that is, a telephone survey in 29 and hospital examination in 23. From the telephone survey, it was learned that patients with a clip are more often wearing elastic compression hosiery and taking oral anticoagulation than controls. They also more frequently report functional complaints. These preliminary telephone findings were confirmed in the patients who were fully examined.

Overall observations are that in patients with a vena cava clip, the following abnormalities are more frequent than in controls. Functional complaints: edema, skin changes, contralateral femoral venous reflux, and inferior vena cava thrombosis. This leads to the greater use of elastic compression and the use of oral anticoagulation. The authors demonstrate that it is the clip which is responsible for the progression of chronic venous insufficiency. They believe that patients with a clip present frequent thrombus distal to the clip and that this thrombus invades the contralateral deep venous system. Their indications for the use of such devices are very limited, and the use of vena cava filters today is much more frequent. Finally, the authors emphasize the need for lower limb physiotherapy in patients with a vena cava clip and feel that this is the best means of preventing distal thrombus extension.

COMMENTARY

This study is very well carried out and the statistical analysis appears to be fully reliable. The patients examined in the hospital were checked in detail. We can consider that the role of the clip in promoting progression of chronic venous insufficiency is correct. Inferior vena cava thrombosis appears to be a complication in 30% of the cases. This figure is not much different from reported cases of inferior vena cava thrombosis following filter placement but in fact this does not increase the reader's interest in a device whose use is considered only in patients undergoing an open surgical procedure.

The subject of prevention of chronic venous insufficiency remains challenging, and the use of physiotherapy and compression must be emphasized once again. 5784b




COMPLICATIONS OF INFERIOR VENA CAVA FILTERS
 Ray CE Jr, Kaufman JA
Abdominal Imaging 1996; 21:368-74

ABSTRACT AND COMMENTARY BY:
Michael J. Rohrer, M.D.
Associate Professor of Surgery
University of Massachusetts
Worcester, Massachusetts

The authors provide a concise description of the evolution of vena cava interruption from early surgical ligation and plication to the current percutaneous placement of filters through small introducer sheaths. A brief review of the "absolute" and "relative" indications for caval interruption are also presented. Further, the six different devices currently available in the United States for vena cava interruption are listed. Complications of inferior vena cava (IVC) filter placement are logically divided into those related to vascular access at the jugular or femoral puncture site, those related to the delivery system (i.e., kinking of the introducer sheath or the development of air embolization), and those due to filter malposition, tilting, and incomplete opening.

The incidence of complications noted in followup, including recurrent pulmonary embolization, penetration of the IVC wall by the struts of the filter, caval thrombosis, filter migration, and miscellaneous complications such as filter struct fracture and dislodgement of filters by endovascular maneuvers (i.e., placement of central venous lines) are listed along with a description of the pathophysiology of each problem.

COMMENTARY

The authors provide a comprehensive and logical review of the rationale for vena caval interruption as well as a valuable identification of the devices available for IVC interruption in the United States. A minor omission is the absence of a description of the role of unrecognized IVC duplication as a contributing factor for pulmonary embolization after IVC filter placement. Although the authors pointed out that the incidence of femoral venous access site thrombosis is higher than clinically suspected, they fail to use this data to advocate the preferability of performing access for IVC filter placement through the jugular venous approach. More importantly, however, they appropriately stress the importance of knowledge of the indications for IVC filter placement as well as the risk of over-utilization of the devices.

The only controversial statement in the manuscript is in the final paragraph where the authors state, "The lack of a controlled study comparing IVC filters with other methods of therapy, such as anticoagulation, puts physicians at a serious disadvantage...; comparative studies are, therefore, necessary before the role of IVC filters can be firmly established." This statement creates the impression that the authors view anticoagulation and placement of an IVC filter as two mutually exclusive and competing modalities for the treatment of venous thromboembolic disease. From the perspective of a clinician treating patients with deep venous thrombosis and pulmonary embolization, the role of IVC filters is very firmly defined and the treatment algorithm very simple. The well-defined natural history of deep venous thrombosis and pulmonary embolism treated by therapeutic anticoagulation makes heparin and Coumadin anticoagulation the obvious treatment of choice. The natural history of DVT and PE in those patients who cannot be anticoagulated, or in those rare patients who suffer a pulmonary embolus despite anticoagulation, is sufficiently dismal that the short- and long-term risk as well as the expense of IVC interruption is clearly justified. 6125b




CLASSIFICATION OF VARICOSE VEIN RECURRENCE AFTER SURGERY (Comment Classer Les RÈcidives Variqueuses AprÈs Traitement Chirurgical)
 Perrin M.
PhlÈbologie 1996; 49:453-60

ABSTRACT AND COMMENTARY BY:
Dr. med. Reinhard H. Fischer
St. Gallen, Switzerland

In this presentation, the authors describe the classification previously published from Edinburgh. Only now this is illustrated in color. The classification describes three types of recurrences. Type 1 includes persistent connections between the deep and superficial venous systems at the level of the saphenofemoral junction. This type requires reexploration of the saphenofemoral connection. Type 1 is divided into three parts. In Group A, a surgical error has caused a tributary vein to be removed but the saphenous vein remains intact. In Group B, an incomplete saphenous vein division has been performed incorrectly, and in Group C, it is apparent that angioneogenesis or a new connection has developed.

In Type 2 recurrences, there is no connection between the superficial and deep system at the level of the saphenofemoral junction. Therefore, the saphenofemoral junction does not need to be reexplored. This type is divided into two groups. In Group A, the varicosities are fed from an internal iliac vein, and in Group B, from the superficial femoral vein through perforating veins in the thigh.

In Type 3, lesser saphenous incompetence not treated by the primary operation is encountered. The author presents several criticisms of the Type 3 classification, and among these criticisms is consideration of sclerotherapy as an alternative to surgical reoperations.

Therefore, the author proposes another classification which considers the etiologic and pathophysiologic elements. He suggests that Group 1 would comprise incorrect interruption of perforating veins including both the saphenofemoral and saphenopopliteal junction. Group 2 would include incomplete surgery due to faulty diagnosis at the primary operation (e.g. a missed incompetent lesser saphenous vein). A third group would include patients with new varicosities developed since the primary operation, and in a fourth group, there would be varices not treated at the first operation. This type of so-called recurrence could be prevented by using postoperative sclerotherapy. A fifth group is proposed which would be recurrence due to strategic mistakes, and the author cites the CHIVA method. Group 6 would be a bad result of primary surgery due to deep venous insufficiency. The author suggests that this type of classification would automatically indicate the therapy to be recommended. The author also suggests the formation of an international consensus group which should propose a classification to be used internationally by all who are interested in this subject.

COMMENTARY

Many classifications of varicose vein recurrences have been described in the past. The proposed classification of Perrin presents certain worthwhile features. The suggestion of an internationally accepted classification may be desirable in the near future. In fact, such a classification might be of benefit in everyday use by interested surgeons. It is important for mutual understanding to compare results internationally, and it is important for quality control as well. However, there are large numbers of different aspects of this subject which have to be considered if a new classification is to be fruitful. This means that the international group proposed would have a tremendous amount of work to do. Perhaps it would be better to wait to see how the new Hawaii classification of chronic venous insufficiency works out. 5795b

SUGGESTED READING

1. Pouliadis GP, Th¸rlemann A. Zur vermeidung von rezidivvarikosen ab leiste (How to avoid recurrences at the saphenofemoral junction). In: Brunner U (Hrsg) Dic Leiste. Reihe Aktuelle Probleme in der Angiologie 38. Verlag Hans Huber, Bern, 1979; 172-81.

2. Stonebridge PA, Chalmers N, Beggs I, et al. Recurrent varicose veins: A varicographic analysis leading to a new practical classification. Br J Surg 1995; 82; 60-62.




OUTPATIENT MANAGEMENT OF SUPERFICIAL VENOUS INSUFFICIENCY AT A NAVAL MEDICAL FACILITY
 Greason KL, Murray JD
Ann Vasc Surg 1996; 10:524-29

ABSTRACT AND COMMENTARY BY:
Bo Eklof, M.D., Ph.D.
Clinical Professor of Surgery
University of Hawaii
Straub Clinic and Hospital
Honolulu, Hawaii

The authors describe their experience from selective therapy based on proximal venous ligation and staged sclerotherapy in 104 patients with symptomatic venous insufficiency. A total of 52% were military personnel on active duty. The remainder were civilians. All patients underwent physical examination including hand-held Doppler examination while duplex scanning was used "selectively." Color photos were taken and patients were fitted with compression stockings. Selective point ligation of the incompetent vein was completed in the operating room under local anesthesia. All patients returned to full duty or work the next day. Six weeks following surgery, patients returned for sclerotherapy using sodium tetradecyl sulfate (average 1%, maximum 5 cc). Patients were instructed to wear compression stockings continuously for two weeks and then during working hours for another six weeks.

Post ligation complications occurred in 18% (wound complications 4%, superficial thrombophlebitis 14%). Post sclerotherapy complications in 4% was due to superficial tape burns. A total of 74% were seen in followup and evaluated for recurrent disease after an average of one year (range 150 to 715 days). Patient satisfaction was extreme in 94% with regard to symptomatic and cosmetic improvement. Total recurrence rate was 12% with 8% in a previously treated vein (true recurrence) and 4% with "new disease." The authors concluded that selective ligation of incompetent veins combined with sclerotherapy achieves the desired results with low morbidity and very high patient acceptance and that economic factors made this an attractive alternative in the treatment of symptomatic varicosities.

COMMENTARY

Chronic venous disease has suffered from lack of precision in diagnosis. This deficiency has led to reports of conflicting results in studies of management for specific problems. These conflicts will be best resolved by precise pretreatment classification of the disease entities based on accurate diagnosis.

In February 1994, these problems were addressed by an international ad hoc committee of the American Venous Forum in Hawaii. This committee produced a consensus document for classification and grading of chronic venous disease based on clinical manifestations (C), etiologic factors (E), anatomic distribution of involvement (A), and underlying pathophysiologic findings (P). This has been termed the CEAP classification. Formally endorsed by the American Venous Forum and by the Joint Councils of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery,1 this classification system has now been published in 19 international journals.

In the current paper, there is no attempt at classification. Duplex scanning has been used selectively but there is no mention of results. Followup was possible in 74% of patients after an average of one year with high patient satisfaction and a recurrence rate of 12%. This experience is common, but with longer observation time, the results deteriorate. For example, Kistner's enthusiasm in 1986 moderated with the passage of time.2 Our own study of 60 patients showed excellent patient satisfaction.3 After five years, 50% were subjectively well. Objective testing using foot volumetry showed initial improvement but after one year there was a deterioration. After five years, only 16% were objectively cured. Similar results have been published by Lofgren of the Mayo Clinic4 and Jacobsen of Copenhagen.5

For the young individual expecting a long-lasting cure, the best chance lies in high ligation combined with stripping of the saphenous vein. This is safely done on an outpatient basis. In the aged patient with less emphasis on recurrence, or with intent to preserve the saphenous vein, point ligation with sclerotherapy can be an alternative. 6138b

REFERENCES

1. Porter JM, Moneta GL. International consensus committee on chronic venous disease. Reporting standards in venous disease: An update. J Vasc Surg 1995; 21:635-45.

2. Kistner RL, Eklof B. Saphenofemoral venous ligation combined with sclerotherapy in treatment of varicose veins. In: Goldman MP, Bergan JJ (eds). Ambulatory Treatment of Venous Disease: An Illustrative Guide. CV Mosby, St. Louis, 1996, pp 155-62.

3. Neglen P, Einarsson E, Eklof. High tie with sclerotherapy for saphenous vein insufficiency. Phlebology 1986; 1:105-11.

4. Lofgren KA. Management of varicose veins: Mayo Clinic experience. In: Bergan JJ, Yao JST (eds). Venous Problems . Year Book Medical Publishers, Chicago, 1978, pp 71-83.

5. Jacobsen BH. The value of different forms of treatment for varicose veins. Br J Surg 1979; 66:182-84




MINI ABSTRACTS
John J. Bergan, M.D.
Items of Interest Which Have Crossed the Editor's Desk
(Provided for reference purposes and general interest)


The Value of Duplex Scanning in Patients With Recurrent Varicose Veins
Grouden MC, Colgan MP Moore DJ, Shanik GD
J Vasc Tech 1996; 137-9

This experienced group from St. James' Hospital in Dublin reveals that of 62 limbs with proximal saphenofemoral junction ligation, 37 were found to have a patent, incompetent saphenofemoral junction and 20 others had an adequately ligated junction but incompetence of the saphenous vein. These findings cast further doubt on the adequacy of the operation of proximal saphenofemoral junction ligation.


Postoperative Thromboembolism After Day-Case Herniorrhaphy
Riber C, Alstrup N, Nymann T, et al.
Br J Surg 1996; 83:420-21

This paper from the University of Copenhagen documents the fact that 2,281 patients had day-case repair of inguinal hernia. Hospital admission for thromboembolism within the first 30 days after surgery was identified in only one patient. His was a non-fatal pulmonary embolism. The authors conclude that there is no need for routine prophylaxis for thromboembolism in day-case hernia surgery.


Colour Flow Duplex in the Assessment of Recurrent Varicose Veins
Khaira HS, Crowson MC, Parnell A.
Ann R Coll Surg Engl 1996; 78:139-41

This report from Burton-on-Trent corroborates many findings of other series. That is, in 23% of limbs scanned, the saphenofemoral junction was intact and, overall, recurrence from the groin was present in 72%. The long saphenous vein was found in 74% of the legs scanned. Clearly, the persistence of a greater saphenous remnant is an important factor in recurrent varicose veins. Although proximal saphenofemoral ligation remains popular in America, studies of recurrent veins show that technique to be a major cause of recurrent varicose veins.


Deep Vein Thrombosis as a Predictor of Cancer
Ahmed Z, Mohyuddin Z.
Angiology 1996; 47:261-65

Although the title of this paper suggests Trousseau's phenomenon, in fact, of 113 patients with primary deep venous thrombosis, only three developed a malignancy subsequently. Although this includes the 83 patients with secondary deep venous thrombosis, the overall incidence of cancer was 3 out of 196. Clearly, screening for malignancy on the basis of deep venous thrombosis is a complete waste of time.