LASER THERAPY OF VARICOSITIES WITH THE FLASHLAMP-PUMPED, PULSED-DYE LASER
Wiek K, Ishkanian S, Vanscheidt W.
Lasers in Med Science 1996; 11:193-97
ABSTRACT AND COMMENTARY BY:
David Green, M.D.
Bethesda, Maryland
In this prospective study, these investigators attempted to eradicate dermal telangiectasias
of the lower extremities through selective photothermolysis. They treated both capillary
telangiectasias (which they described as "early red varicosities") and venous telangiectasias ("more developed blue varicosities") using a flashlamp-pumped,
pulsed-dye laser with a wavelength of 585 nanometers, pulse duration of 450 microseconds,
and a spot size of 5 mm. The energy density used ranged from 6.5 to 8.0 joules/cm2. Prior to treatment, telangiectasias were examined by high-frequency (20 MHz), high-resolution
duplex ultrasound scanning, and those findings were correlated with the clinical
appearance of the telangiectasias. The "red varicosities" had diameters up to 0.36 mm with an average depth of 0.4 mm. The "blue varicosities" had diameters beteeen
0.44 to 1.1 mm with an average depth of 0.6 mm.
Red telangiectatic vessels were successfully removed by repeated treatment, the blue
telangiectatic vessels responded, and the reticular varicose veins failed to respond
at all. Several different treatment protocols were followed. In particular, there
was a 20% success rate in eradicating blue telangiectasias treated once with energy
densities of 7.0 to 8.0 joules/cm2. When these blue telangiectasias were treated over three sessions (once every three
weeks) with an average density of 7.5 joules/cm2, a success rate of 30% was achieved. Using 6.5 joules/cm2 and two consecutive pulses in one session, none of the treated blue telangiectasias
responded. Reticular veins failed to respond to two treatment sessions using 8.0
joules/cm2. A success rate of 100% was achieved in eradicating red telangiectasias treated
with 7.5 joules/cm2 in three sessions once every three weeks. Similar red telangiectasias treated with
two pulses of 6.5 joules/cm2 during one session resulted in only a 54% rate of disappearance.
COMMENTARY
These investigators demonstrated nicely the utility and limitations of the flashlamp-pumped,
pulsed-dye laser in the treatment of telangiectasias. Their reported success rates
for varicose veins (including reticular varicose veins), venous telangiectasias, and capillary telangiectasias are in concordance with those who have treated similar
lesions with similar light sources. The success rate for treating venous "blue"
telangiectasias of 20 to 30% compares unfavorably with sclerotherapy.
As many others have discovered, sclerotherapy is a more effective modality for treating
venous "blue" telangiectasias than is photothermolysis. For this reason, manufacturers
have modified their lasers in an attempt to improve efficacy and reduce adverse sequelae. Within the past year this has included widening the pulse duration from
450 to 1500 microseconds, offering longer wavelengths of 590, 595, and 600 nanometers,
and providing simultaneous cooling of the overlying skin to diminish adverse cutaneous effects and permit the skin to tolerate higher energy densities. Even with these
innovations, however, varicose veins remain relatively unresponsive to photothermolysis,
and venous telangiectasias are still more safely and effectively treated by sclerotherapy. Many other sources available are even less effective than the pulsed-dye
laser as these investigators demonstrated with an argon laser.
It should be noted that these investigators observed pigmentary disturbance in 100%
of treated patients (82% hyperpigmentation, 18% hypopigmentation). Hyperpigmentation
was directly correlated with energy density and hypopigmentation with complexion.
The three innovations of the pulsed-dye laser noted above reduce the incidence of pigmentary
alteration and other adverse effects while increasing efficacy and reproducibility
of treatment. These authors are to be commended for publishing their data even though it reflects a relative lack of efficacy for certain venous lesions and a high
rate of adverse effects (100% incidence of pigmentary alteration). The 100% success
rate in eradicating capillary "red" telangiectasias is indeed impressive. Since
these respond poorly to sclerotherapy, it is heartening to know that a successful treatment
modality is available. 6410b
SQUAMOUS CELL CARCINOMA ARISING IN CHRONIC LYMPHEDEMA
Lister RK, Black MM, Calonje E, et al.
Br J Dermatol 1997; 136:384-87
COMMENTARY BY:
Mitchel P. Goldman, M.D.
La Jolla, California
This is a short report regarding two patients with chronic leg lymphedema who developed
squamous cell carcinoma. The authors review the pathogenesis of malignant tumors
in chronic lymphedema. The two case reports should stimulate interest in biopsying
any chronic wounds of the leg in patients with lymphedema. For instance, chronic warty
hyperkeratosis and lymphocytosis varicosa cutis may actually evolve into squamous
cell carcinoma. Thus, biopsy of particularly atypical lesions in these conditions
is warranted. 6415b
MINIMALLY INVASIVE SURGERY FOR PERFORATOR VEIN INCOMPETENCE
Saharay M, Scurr JH
Cardiovasc Surg 1996; 4:701-705
ABSTRACT AND COMMENTARY BY:
Andrew W. Bradbury, BSc, MD, FRCSEd
Edinburgh, United Kingdom
This review article offers a brief outline of the history of the management of venous
ulceration, a synopsis of the venous anatomy of the lower limb, an overview of a
pathological classification of calf perforating veins, and an approach to noninvasive
perforator assessment. It then reviews the surgical techniques of open and minimally
invasive perforator interruption. The paper covers the contentious areas of normal
calf physiology, results of perforator surgery, and indications for perforator interruption.
COMMENTARY
The history of venous surgery with respect to ulceration is concise and pertinent.
Particularly the authors highlight the contributions of Linton and Cockett, and
those who later modified their techniques. There is a brief description of the venous
anatomy of the lower limb supported by an excellent schematic diagram showing the location
of the main perforator groups.
The authors then go on to give an account of calf perforating vein physiology and
they classify incompetent perforating veins (IPV) into four types. This classification
is unreferenced and appears to be the authors' own. Although not a classification
that we ourselves would favor or use, the absence of an universally accepted classification
serves to show how little is known about the basic pathophysiological mechanisms
underlying chronic venous insufficiency.
Our own classification is based on the distribution of the reflux feeding the incompetent
perforating veins and the type of venous surgery required to correct bidirectional
perforator blood flow.
1. Type I incompetent perforating veins (IPV) are fed by a refluxing saphenous vein
(long and/or short) in the presence of a normal deep system. Our data indicate that
in two-thirds of such cases, saphenous surgery alone will correct bidirectional perforator flow.
2. Type II IPV are found in association with isolated deep venous reflux. That is,
there is no significant saphenous reflux. In these circumstances, IPVs require surgical
interruption as bidirectional flow is not corrected by saphenous surgery.
3. Type III IPV are found in association with mixed superficial and deep venous reflux.
Again, our own data strongly suggest that in these cases, perforator interruption
is required to abolish bidirectional flow and that saphenous surgery alone is inadequate.
4. Type IV IPV act as part of the collateral circulation bypassing an occluded deep
venous segment. It is important that such IPVs are clearly identified since perforator
interruption, with or without saphenous extirpation, will be detrimental to these
patients.
The authors quite correctly highlight the widely disparate results reported from perforator
surgery. We totally agree that this may, in large part, be due to inappropriate
case selection. For example, with regard to our classification, we would not expect patients with Type I IPV to gain any additional hemodynamic or clinical benefit from
perforator ligation performed in association with standard saphenous surgery. Furthermore,
perforator ligation in patients with Type IV IPV would be contraindicated.
In order to define precisely the pattern of venous reflux and thus the nature of the
surgery required, we routinely perform a duplex scan on all patients immediately
prior to venous surgery, particularly when considering the patient for subfascial
endoscopic perforator surgery (SEPS).
In summary, the authors have provided an useful overview of the possible role of IPV
in chronic venous insufficiency. Although we understand that constraints on space
may have limited the discussion, the section on the SEPS procedure could have been
expanded. Particularly, the advantages and disadvantages of the various different techniques
used in Europe and North America could have been explored more fully. 6411b
LEG ULCERS IN KLINEFELTER SYNDROME: FURTHER EVIDENCE OF AN INVOLVEMENT OF PLASMINOGEN
ACTIVATOR INHIBITOR-1
Zollner TM, Veraart JCJM, Wolter M, et al.
Br J Dermatol 1997; 136:341-44
COMMENTARY BY:
Mitchel P. Goldman, M.D.
La Jolla, California
The authors present a series of patients with Klinefelter syndrome who developed leg
ulcerations. They looked at a similar number of patients with Klinefelter syndrome
who did not develop leg ulcerations. After analyzing various factors including age,
body mass, C-reactive protein, testosterone, smoking, and the presence of diabetes mellitus
and arterial hypertension they found no significant difference between these two
groups except for a higher activity of plasminogen activator inhibitor-1 (PAI-1)
in patients with leg ulcerations. They conclude that PAI-1 activity is not elevated in
Klinefelter syndrome in patients in general, but it is elevated in a subset of these
patients who develop leg ulcerations. The obvious message is that patients with Klinefelter syndrome who develop leg ulcerations should be evaluated for PAI-1. Androgen
therapy, known to reduce PAI-1 activity, should be explored as a possible treatment
modality. 6416b
RETROGRADE FLOW IN THE DEEP VEINS OF SUBJECTS WITH NORMAL VENOUS FUNCTION
Lagattolla NRF, Donald A, Lockhart S, Burnand KG
Br J Surg 1997; 84:36-39
ABSTRACT AND COMMENTARY BY:
Nicos Labropoulos, M.D.
Loyola University Medical Center
Maywood, Illinois
The authors evaluated the effect of leg positioning on deep vein retrograde flow induced
by distal standard cuff decompression and during Valsalva maneuver. A total of 61
limbs of 34 patients without signs and symptoms of chronic venous insufficiency and
with normal foot volumetry were enrolled in the study. The retrograde flow in the
superficial femoral (above and below knee), popliteal, and posterior tibial veins
was determined by duplex ultrasound with each patient inclined at 10 degrees, 45
degrees, and standing erect. It was demonstrated that reverse flow in the erect position was
significantly less than in the femoral and popliteal veins compared to those in the
inclined positions. Reverse flow of more than 0.5 seconds was never seen in the
posterior tibial vein in the erect position or in the popliteal vein during Valsalva maneuver.
It was concluded that evaluation of retrograde flow should be done during standing
with removal of distal compression in the posterior tibial veins and during Valsalva
maneuver in the popliteal vein.
COMMENTARY
It is largely accepted that detection of venous reflux by duplex scanning is best
evaluated in the erect position with the cutoff point for determining reflux from
normal retrograde flow being 0.5 seconds. This value was obtained by examining 32
normal subjects, 95% of whom had a retrograde flow of less than 0.5 seconds.1 A later study determined that only one of the 120 vein segments in 15 normal subjects
had a reverse flow exceeding 0.5 seconds.2 In accordance with the literature, these authors found that 93% of their normal
subjects had a retrograde flow of less than 0.5 seconds.
Because a considerable number of refluxing vein segments in the inclined positions
were normalized in the erect position, the authors recommend that evaluation of reflux
should be performed in the standing position. The erect position is the most appropriate to determine the presence of reflux. Thus, this method should be adopted by those
who still use inclined positioning.
The authors suggested use of the Valsalva maneuver for evaluating superficial femoral
and popliteal vein reflux rather than removal of distal compression because no reflux
was elicited in either vein with the former method. This statement may not be true
as the Valsalva maneuver is not as strong a stimulus to elicit reflux in those veins
as removal of distal compression. For this reason, other investigators have used
the Valsalva maneuver only in the groin area. I agree with the authors that the
value of isolated reflux is unknown but this is not a reason to perform Valsalva testing in
the popliteal vein.
Three of 10 subjects had reflux in the superficial femoral vein alone. The authors
suggest that this reflux can be explained by the absence of valves proximal to the
femoral vein. This cannot be true since the most constant valve in the deep venous
system lies just below the junction with the deep femoral vein in approximately 90% of
lower limbs.3,4 Therefore, if this valve was normal, reflux would have been absent unless the superficial
femoral vein had isolated reflux below its first valve. 6413b
REFERENCES
1. van Bemmelen PS, Bedford G, Beach K, Strandness DE. Quantitative segmental evaluation
of venous valvular reflux with duplex ultrasound scanning. J Vasc Surg 1989; 10:425-31.
2. Sarin S, Sommerville K, Farrah J, Scurr JH, Coleridge Smith PD. Duplex ultrasonography
for assessment of venous valvular function of the lower limb. Br J Surg 1994; 81:1591-95.
3. Powell T, Lynn RB. The valves of the external iliac, femoral, and upper third
of the popliteal vein. SG&O 1951; 92:453-55.
4. Basmajian JV. The distribution of valves in the femoral, external iliac, and common
iliac veins and their relationship to varicose veins. SG&O 1952; 95:537-42.
EFFECTS OF VARICOSE VEIN SURGERY ON VENOUS FUNCTION OF THE LOWER LIMB
Moor PS, Travers JP, Makin GS
Phlebology 1996; 11:95-97
ABSTRACT AND COMMENTARY BY:
Clifford M. Sales, M.D.
Union Hospital/Saint Barnabas Medical Center
Belleville, New Jersey
This brief article aims to investigate the physiologic benefit of varicose vein surgery.
The authors examined a small subset of patients (15 in the treatment group and 10
in the control group) using only plethysmographic techniques. They ligated some
of the saphenous veins in the treatment group and stripped others without discussing
whether there were differences in the two treatment modalities. The only statistically
significant findings were that venous refilling time (VRT) increased following surgery and that VRT was longer in controls than in the preoperative state of patients
undergoing venous surgery!
COMMENTARY
Identifying the value of this report in furthering our knowledge of venous disease
requires extensive work on the part of the reader. While the authors correctly point
out that "plethysmography is an useful investigative tool to the vascular surgeon,"
they do little to prove that point. That VRT differs in patients with and without venous
reflux is barely noteworthy in the 1990s. Additionally, the authors chose to ignore
the value of the duplex ultrasound examination in their assessments. They overlooked a "landmark" study by Walsh and Bergan1 which examined this topic with much greater scientific rigor. That important paper
documented for the first time that the true physiologic benefit to superficial venous
surgery was in its ability to correct deep venous reflux. Those authors furthered
the "overflow theory" of deep venous incompetence and provided impressive data to support
their points. Our investigations confirmed the observations of Walsh and Bergan.2 The present paper has a provocative title with little to follow. 6139b
2. Sales SM, Bilof ML, Petrillo KA, Luka NL. Correction of lower extremity venous
incompetence by ablation of superficial venous reflux. Ann Vasc Surg 1996; 10:186-90.
A STUDY OF THE MECHANISMS BY WHICH HEMODYNAMIC FUNCTION IMPROVES FOLLOWING LONG SAPHENOUS
VEIN-SAVING SURGERY
Hammarsten J, Bernland P, Campanello M, et al.
Phlebology 1996; 11:102-105
ABSTRACT AND COMMENTARY BY:
Jeffrey L. Ballard, MD, FACS
Associate Professor of Surgery
Loma Linda University Medical Center
Loma Linda, California
The authors studied potential mechanisms by which hemodynamic function improved following
greater saphenous vein-saving surgery in 20 patients with primary varicose veins.
Prior to surgery, all patients underwent extensive evaluation which included physical examination, strain-gauge plethysmography, phlebography, and measurement of the
greater saphenous vein diameter at four sites using high-resolution, real-time ultrasound.
Vein diameter was measured just below the saphenofemoral junction, at mid-thigh,
10 cm above the knee, and 10 cm below the knee.
During surgery, terminal tributaries of the greater saphenous vein (GSV) were ligated
and divided through a 10 mm groin incision. Flush ligation and division of the GSV
was also performed. Incompetent perforators which had been detected by preoperative
phlebography were ligated through 2 to 3 mm skin incisions. Finally, localized varicosities
were avulsed through multiple stab incisions.
Three months following this long saphenous vein-saving surgery, all patients were
reassessed by physical examination, strain-gauge plethysmography, and measurement
of the GSV diameter. At the time of followup, all but one patient demonstrated excellent
or good clinical results. Greater saphenous vein diameter was reduced at all four measured
sites (p < 0.01) and venous return time was prolonged from a mean of 3.6 seconds
to 8.8 seconds (p < 0.001). There was positive correlation between decreased diameter of the long saphenous vein and increase in venous return time (r = 0.50, p = 0.04).
The authors conclude that interruption of incompetent perforators led to a decrease
in greater saphenous vein diameter, largely due to a decline in intraluminal pressure
within the GSV. This reduction in GSV diameter in turn restores valvular competence
due to better apposition of valve leaflets and improved hemodynamic venous function
of the lower extremity.
COMMENTARY
A major point potentially lost with a hasty reading of this article is that incompetent
perforator veins were detected and localized by phlebography. These were then directly
attacked and ligated at the time of surgery which also included greater saphenous vein preservation. Perforator ligation prevented reentry of flow into the deep
venous system. Therefore, reflux down the greater saphenous vein was interrupted.
Interestingly, the article points out that one patient had no reduction in saphenous
vein diameter and only minimal prolongation of venous return time at the time of followup.
When that patient was again studied by postoperative phlebography, there was an
incompetent calf perforator which had apparently been overlooked preoperatively.
It is also noteworthy that although there was a correlation between the reduction
of the greater saphenous vein size and prolongation of venous return time, there
was a fairly wide variation with an "r value" of only 0.50. Despite this, these
data suggest that development of incompetent perforators is an early event in the formation of
primary varicose veins. The authors also suggest that increased intraluminal pressure
within the greater saphenous vein and its tributaries results from abnormal deep
to superficial venous flow through incompetent perforators. Further, valvular incompetence
and reflux within the greater saphenous vein is more likely attributable to venous
wall dilatation rather than degeneration of valves, particularly in patients with
no prior history of superficial thrombophlebitis.
In our practice, it appears that removing the greater saphenous vein and its perforator
connections from the saphenofemoral junction to the knee produces the best hemodynamic
effect and that, in fact, we are able to correct deep venous reflux when we do this. Saving the entire greater saphenous vein is not necessary especially when one
preserves the saphenous vein below the knee. This also minimizes the risk of saphenous
nerve injury which can accompany stripping of the greater saphenous vein in the leg.
Additionally, there are other bypass conduits available in most patients other than
the greater saphenous vein.
We feel that recurrence of primary varicose veins is greatly reduced by saphenous
vein removal instead of ligation at the saphenofemoral junction.
Finally, we have found duplex ultrasonography is accurate in the detection of both
thigh and calf perforators. Phlebography is generally unacceptable to patients in
the United States, and we have essentially eliminated this from the preoperative
workup of patients with chronic venous insufficiency unless a deep venous procedure is contemplated.
6414b
LA MALADIE VARIQUEUSE: ORIENTATIONS ACTUELLES DU DIAGNOSTIC ET DE LA THŠRAPEUTIQUE
(Diagnosis and Treatment of Varicose Veins)
Guex JJ
Le Mouvement Cardiovasculaire 1996; 245-49.
ABSTRACT AND COMMENTARY BY:
Michel Perrin, M.D.
Vascular Surgery, Clinique du Grand Large
Lyon, France
This article is an overview on the diagnosis and treatment of varicose veins and was
prepared by an extremely active French phlebologist. After preliminary commentary,
he formulates a number of questions and tries to answer each. For example, in the
case of each patient seen, he tries to ascertain which kind of varicose disease is present,
whether or not duplex scanning will be necessary, and whether treatment of the problem
is useful or mandatory. He also discusses the current treatments of varicose vein disease and which type is recommended in differing types of varicose veins. He
proposes an algorithm but this is not perfectly clear. Thus, it will not be reproduced
here.
COMMENTARY
We agree with the majority of the statements proposed by the author in this article.
The diagnosis and treatment of venous pathophysiology should be undertaken by physicians
who are well trained and educated in the field of phlebology. Furthermore, the treatment alternatives should not be confined to those of any individual physician.
For example, a medical phlebologist should not always prescribe sclerotherapy.
Neither should a surgeon prescribe surgery for all types of varicose vein abnormalities.
The differing types of treatment, including compression/sclerotherapy, and surgery/sclerotherapy
are well described by Guex in this article.
We also appreciated the paragraph devoted to functional signs and symptoms, such as
leg heaviness, which are discussed by Guex as often not related to varicose disease.
In the French language, varicose disease (la maladie variqueuse) is not a precise
or well-defined term. This may also be true in English. For example, does the term include
telangiectasias, varicose veins, and severe chronic venous disease or is it limited?
In the United States, severe chronic venous disease is termed chronic venous insufficiency.
This article does not contain a description of the utility of ambulatory venous pressure
or air plethysmography or even other volume plethysmographies. Furthermore, deep
venous reconstructive surgery is not mentioned, but apart from that, this article
is very well written by a mature angiologist. 6375b
DAY CARE SURGERY OF VARICOSE VEINS IN ELDERLY PATIENTS
Canonico S, Campitiello F, Pacifico F, et al.
Vasc Surg 1996; 30:387-93
ABSTRACT AND COMMENTARY BY:
David L. Rollins, M.D.
Cleveland, Ohio
This article addresses the safety, efficacy, and acceptance of day care varicose vein
surgery in patients over age 65. The authors operated on 51 limbs in 45 patients
(90% female, mean age 69) and performed a variety of procedures, including long and
short saphenous ligations and strippings, extensive phlebectomy, and perforator ligations.
This group of patients represented approximately 14% of the authors' entire varicose
vein surgical group of 500 patients operated on over a three-year period. Those
with bilateral varices were staged. Over two-thirds had short saphenous ligations and/or
strippings, and only ten (20%) had proximal saphenous procedures. All patients
underwent regional nerve blocks with mepivacaine supplemented by dilute subcutaneous mepivacaine around large varices.
Standard varicectomy procedures were used to remove all veins, patients were placed
in 40 mm gradient elastic support, and all were discharged from the hospital within
five to six hours of the operation. There were only two minor complications of wound infection
(4.3%).
COMMENTARY
The authors have demonstrated the safety and efficacy of outpatient treatment of healthy,
elderly patients with little morbidity. As the population continues to age, we are
continually faced with healthier geriatric individuals presenting with severe symptoms and complications of superficial chronic venous disease. Outpatient venous surgery
has been standardized in the United States and may be performed on almost all patients,
even those with stable chronic diseases. Use of newer general anesthetic agents such as propofol combined with lidocaine injection and/or epidural anesthesia allows
for extensive variceal ablation without increased anesthetic morbidity. The use
of dilute lidocaine/ mepivacaine for subcutaneous infiltration anesthesia combined
with saphenofemoral or saphenopopliteal ligation and phlebectomy using the Muller technique
is also becoming more popular. As economic pressures concerning increased costs
of health care continue to grow, it is possible that variceal ablation surgery may
become even more of a "local anesthesia" procedure.
The authors have pointed out nicely that healthy geriatric patients who require varicose
vein surgery may be safely and successfully treated as an outpatient and age alone
should not be considered as an exclusion criteria. 6417b
MINI ABSTRACTS
John J. Bergan, M.D.
Items of Interest Which Have Crossed the Editor's Desk
(Provided for reference purposes and general interest)
Deep Vein Thrombosis
Tyrrell MR, Birtle AJ, Taylor PR
BJCP 1995; 49:5-252-56
This very nice review directed toward physicians in England is a timely update on
the subject of diagnosis and treatment of deep venous thrombosis. It is quite authoritative
and contains an enormous number of relevant references.