VD410R

MINIMALLY INVASIVE SURGERY FOR PERFORATOR VEIN INCOMPETENCE
Saharay M, Scurr JH
Cardiovasc Surg 1996; 4:701-5

SIMPLE TECHNIQUE FOR ENDOSCOPIC SUBFASCIAL DISSECTION OF PERFORATING VEINS
Kok KYY, Goh P, Tan WTL
Br J Surg 1997; 84:333

TIBIAL NERVE DAMAGE DURING SUBFASCIAL ENDOSCOPIC PERFORATOR VEIN SURGERY
Whiteley MS, Smith JJ, Galland RB
Br J Surg 1997; 84: 512

ABSTRACT AND COMMENTARY BY:
John J. Bergan, M.D.
Professor of Surgery
Loma Linda University Medical Center
Clinical Professor of Surgery
University of California, San Diego

These three articles taken together show that subfascial endoscopic perforator vein surgery has taken hold worldwide and the use of video-endoscopic techniques has made the operation more tolerable. Saharay and Scurr provide a cogent summary, an excellent diagram, and an intelligent historical review of the subject. They correctly emphasize the importance of superficial venous reflux in the venous ulcer syndrome and point to the ease of duplex imaging in such situations. Their excellent reference list justifies obtaining the article in its original form, and their final statement summarizes the present position of the operation. They say, "endoscopic perforator ligation has significant advantages over traditional open subfascial ligation and should be the choice in patients with trophic skin changes where perforator ligation is contemplated."

In the article from Singapore, the authors suggest the use of a 2.5 cm proctoscope within which a 5 mm video-laparoscope is introduced. As dedicated instruments by ETB in Berlin and Wolff in Germany are available, it is highly unlikely that this technique will be adopted. On the other hand, their emphasis that endoscopic subfascial ligation of perforating veins has many advantages is certainly true.

In the case report from Reading, the authors incorrectly point out that tibial nerve injury has not been reported. Actually, a number of reports from Europe emphasize the dangers of this complication. However, in this article from England, the anatomy of the posterior tibial nerve is described, and the dangers of passing operating instruments below the medial malleolus at the ankle are correctly emphasized.

COMMENTARY

Although in the remote past, therapeutic nihilism characterized surgical approaches to venous ulcer, these articles emphasize two points that make venous ulcer a true surgical diagnosis. The first is that superficial venous reflux may be the only problem encountered in dealing with recalcitrant venous ulceration. In this situation, the perforating veins serve two deleterious purposes. One is to direct muscular compartmental pressure outward into unsupported venules of the subdermis and skin and the other to direct superficial reflux into the deep venous system, thus overloading the deep veins and causing them to elongate and dilate. The second point of emphasis is that subfascial perforator vein interruption by video-endoscopic techniques allows outpatient surgery to be done with minimal invasion, rapid mobilization, and total absence of hospitalization.

While interested venous scientists argue the importance of perforating veins, clinical surgeons are rapidly taking up the procedure because of its benefits which are obvious to the clinical personnel attending the patients. 6549b

SUBFASCIAL ENDOSCOPIC PERFORATOR LIGATION: AN ANALYSIS OF EARLY CLINICAL OUTCOMES AND COST
Iafrati MD, Welch HJ, O'Donnell TF.
J Vasc Surg 1997;25:995-1001.

ABSTRACT AND COMMENTARY BY:
Roy L. Tawes, Jr. MD
Clinical Professor of Surgery
University of California, San Francisco
Burlingame, California

The Tufts-New England Medical Center vascular surgeons report their early subfascial endoscopic perforator surgery (SEPS) experience with 18 procedures and analyze the outcomes and costs. The patients were CEAP class 4 to 6, properly documented and mapped preoperatively with duplex scanning.

As expected, the outcomes were good in all those with complete perforator interruption (86%). Four patients with residual perforators did not heal their ulcers (not unexpected). The surgeons found operating room costs were greater with the SEPS technique than with limited open incisions ($2570 vs $1883). They admit a 'learning curve' with the endoscopic technique and shortened their operative time later in their experience. This made the operation more cost efficient toward the end of the study. The authors conclude that increased operating room costs associated with longer operations and greater disposable expenses will likely be overcome by decreased length of stay and wound complications. They emphasize the importance of ligating all incompetent perforating veins as ulcers did not heal when residual or missed perforating veins were found in the postoperative followup period (mean 22 months).

COMMENTARY

In the past two years, our group, the Peninsula Vascular Surgery Associates, has performed over 100 SEPS procedures. Our major observations support the conclusion of the Tufts' group that patients with residual or missed incompetent perforators will not heal. We have five such failures. The 'big ticket' items in assessment of costs are length of stay and operating room costs (operating time and materials). Each decrease of one-tenth of a day in our hospital yielded a savings of $440,000 over a one-year period. A true economy of scale is to perform same-day surgery in these patients. We accomplished this in all but 9 patients, representing a major cost reduction. A cost not factored into the Tufts study is the decrease in wound morbidity, readmission rate, and office followup associated with the SEPS patients compared historically to those having open Linton procedures, or modifications thereof, for perforator interruption. Clearly, SEPS is a major advance in surgical technology contributing to cost-effectiveness in the total treatment of venous insufficiency.

Operating room costs are minimized by preoperative mapping with the duplex scanner and creation of a good subfacial working space in order to efficiently identify and clip the incompetent perforators. This also saves considerable time and effort. We use the Spacemaker Balloon (General Surgical Innovations, Palo Alto, California) and CO2 insufflation to optimize the exposure and decrease the operative time for the SEPS procedures. We average about 20 minutes for this part of the operation. In contrast to the Tufts study, our impression is that SEPS techniques shorten the operative time. Additional cost savings may occur with reuse of many of the instruments used for dissection.

Reviewing our past experience with Linton procedures, our hospital business office informed us that the new SEPS technique has decreased hospital costs by a factor of 3 to 4 times. This is essentially the result of shortened lengths of stay and decreased wound morbidity resulting in fewer readmissions for post-operative wound complications. tawes.doc

LATERAL VENOUS ULCER AND SHORT SAPHENOUS VEIN INSUFFICIENCY
Bass A, Chayen D, Weinmann EE, Ziss M
J Vasc Surg 1997; 25:654-57

ABSTRACT AND COMMENTARY BY:
James O. Menzoian, M.D.
Boston University School of Medicine
Boston, Massachusetts

The authors report on 20 patients who present with venous ulcers in an unusual location - near the lateral malleolus. All ulcers had been present for more than one year with an average ulcer duration of 24 months. No patient had the typical skin changes on the medial ankle associated with venous ulceration (i.e., hyperpigmentation or lipodermatosclerosis).

Because of the unusual location and appearance of the ulcers, 15 patients were treated for a non-venous diagnosis. They underwent venous noninvasive testing by continuous-wave Doppler examination and color-flow duplex imaging. The tests were performed with the patient standing using the calf compression technique. There was no evidence of obstruction or valvular incompetence in the deep venous system or perforating veins in any patient. All were found to have incompetence at the saphenopopliteal junction (SPJ). No other venous abnormalities were found.

The authors describe a very nice technique for preoperative marking of the SPJ. The ligation was flush with the popliteal vein and all venous tributaries in the area were identified and ligated. Followup of these patients ranged from 12 to 36 months. One ulcer recurred nine months after ligation of the saphenopopliteal junction. This patient had undergone radiation treatment of the leg 20 years earlier, and the authors suggest that the recurrence could be related to severe radiation dermatitis.

COMMENTARY

The authors point out an interesting phenomenon on etiology of venous ulcers in unusual locations. We have all seen ulcers on the lateral portion of the lower leg and the usual differential diagnoses of these ulcers (other than arterial insufficiency) include hypertensive ischemic ulcers, ulcers related to hematologic disorders, and ulcers from vasculitis. These authors remind us that the possibility of ulcers being related to venous insufficiency must be considered. They also point out that the usual noninvasive evaluation of these extremities was quite unremarkable. It was only when interrogation of the lesser saphenous vein and the popliteal junction by Doppler was done that this uncommon abnormality was identified.

In patients with ulcers in unusual locations, especially the lateral foot, venous insufficiency is certainly something the clinician should consider. 6829b

COLOR DUPLEX ULTRASONOGRAPHY IN THE RATIONAL MANAGEMENT OF CHRONIC VENOUS LEG ULCERS
Grabs AJ, Wakely MC, Nyamekye I, et al.
Br J Surg 1996; 83:1380-82

ABSTRACT AND COMMENTARY BY:
Ralph G. DePalma, M.D.
Associate Dean & Vice Chairman of Surgery
University of Nevada
Reno, Nevada

The authors used color duplex ultrasonographic imaging to assess patients with chronic venous ulceration in community ulcer clinics. Patients were selected on the basis of ankle brachial indices greater than 0.85. Reflux was defined as reverse flow greater than one second after manual calf compression.

A total of 100 consecutive patients (111 ulcerated limbs) were studied over 15 months with 96 having active ulceration and 15 being ulcerated in the previous six months. A total of 57 (51%) had superficial incompetence alone (88% in the greater saphenous system or its perforators, and 12% in the lesser saphenous system). Six limbs (5%) had isolated deep venous incompetence while 42 limbs exhibited mixed superficial and deep venous reflux.

The authors conclude that the demonstration of superficial venous disease in approximately half of the limbs with ulceration shows that venous dysfunction in these patients is potentially curable by surgery.

COMMENTARY

This study makes two important points: 1) Color duplex ultrasonographic imaging is necessary prior to treatment of venous ulceration, and 2) gravitational force due to superficial venous incompetence is a major contributor to chronic venous insufficiency.

Treatment of superficial disease is a logical first step in treating chronic venous insufficiency. In my own series1, saphenous stripping was part of the treatment in 55% while Bergan's duplex study of advanced chronic venous insufficiency demonstrated that 17% of limbs had superficial reflux alone and that superficial reflux was a major contributor to chronic venous insufficiency in approximately 30% of patients with combined insufficiency.2

It is important to re-emphasize the contribution of superficial reflux in skin ulceration due to venous disease. This study emphasizes the view that advanced skin changes do not depend solely on a prior episode(s) of deep venous thrombosis. Screening for venous disease using duplex ultrasonography as the main tool also warrants re-emphasis. A followup paper by the authors on the efficacy of surgical treatment would be desirable in this well-characterized series. 6591b

REFERENCES

1. DePalma RG. Surgical therapy for venous stasis: Results of a modified Linton operation. Am J Surg 1979; 137:810-13.

2. Bergan JJ. New developments in surgery of the venous system. Cardiovasc Surg 1993; 1:624-31.

MANAGEMENT OF EXTERNAL HEMORRHAGE FROM VARICOSE VEINS
Bergan JJ
Vasc Surg 1997; 31(4):413-18

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

This careful report of a series of 20 patients who experienced external varicose bleeding presented by John Bergan, M.D. is highly useful to all phlebologists. It emphasizes and details the varicose background of these patients, points out the importance of the problem, and provides complete guidelines for management of this very seldom described complication.

To summarize this paper, we could describe a typical case - an elderly woman with ancient and untreated varicose veins experiences a "jet bleed" of a venous bleb while toweling after a hot bath. Alarmed by an important blood loss (not immediately controlled by manual compression), her general practitioner refers her to a vascular specialist who searches for reflux with a hand-held Doppler, carries out local sclerotherapy, adds a serious compression, and orders a duplex examination. The duplex reveals junctional incompetence and the need for surgery and additional sclerotherapy. After appropriate surgical treatment associated with careful followup, the patient has no bleeding recurrence.

Though this is only a caricature made by the abstractor, it represents close to one-third of the cohort presented by Bergan. Clinical variations are detailed and it can be observed that hemorrhages may occur in any severe varicose status at any age. It is especially interesting to read, for example, that none of these patients bled from a venous ulcer and that excessive height might be a causal factor in younger patients.

The author has made an extensive review of the literature on the topic and provides us with many important considerations regarding the potential danger of venous bleeding. Pathophysiologic mechanisms are discussed in depth as well but no explanation is given to bleeding without any trauma. We have suggested in a previous paper that dermatitis was responsible for a spontaneous microthrombosis of the venous blebs and that, owing to the fineness of the epidermis, a hemorrhage could occur at the time of the clot lysis.1 These microthromboses are very often observed as prominent, hard, dark blue grains. Their treatment is simple puncture and removal of the microclot with a scalpel, sclerotherapy of the adjacent varicosities, Vaseline dressing, and compression. We recommend looking for these lesions in elderly patients with extensive varicosities because treatment of these will hopefully avoid the hemorrhages.

The algorithm provided by Bergan for diagnosis and treatment is complete and accurate. However in Europe, duplex examination would be carried out in all patients since this is done by the vascular specialist himself as a routine examination. The need for immediate sclerotherapy is well emphasized as is the danger of attempting a venous suture (leading to ulceration).

In conclusion, the author did an excellent job in pointing out this potentially lethal complication of varicose disease. 6852b

REFERENCE

1. Guex JJ. Les telangiectasies pre-hemorragiques. Phlebologie 1995; 48(1):41-42.

INFLUENCE OF HEALING ON THE DISTURBED BLOOD FLOW REGULATION IN VENOUS ULCERS
J�nger M, Hahn M, Klyscz T, Rassner G.
VASA 1996; 25:341-48

ABSTRACT AND COMMENTARY BY:
Nicos Labropoulos, M.D.
Section of Peripheral Vascular Surgery
Loyola University Medical Center
Maywood, Illinois

This study examined the influence of healing on the cutaneous microcirculation of patients with venous ulcers. Twelve healthy volunteers (controls) and six patients with recurrent venous ulcers were included. The presence of venous disease was documented by continuous-wave Doppler. Arterial disease was excluded by means of ankle brachial index. The cutaneous microcirculation was evaluated by laser Doppler fluxmetry at the level of the medial malleolus using the following testing: Post occlusive hyperemia, passive leg elevation to 28 cm above heart level, passive lowering of the leg to 33 cm below heart level, and venous occlusion by inflation of a thigh cuff to 70 mmHg. In all the above measurements, significant differences were shown between the controls and the patients with venous ulcer. Ulcer healing did not improve any of the parameters measured.

COMMENTARY

In this study, it was shown that the skin micro-circulation in patients with recurrent venous ulcers was altered compared to controls and that healing of the ulcers did not alter any of the parameters measured.

It is widely accepted that the regulation of cutaneous blood flow in areas of skin damage in patients with chronic venous disease is disturbed. Recent reports have demonstrated that the skin blood cell flux increased with worsening of chronic venous insufficiency (CVI)1-3 while the vasodilatation response in post occlusive hyperemia is reduced. The venoarteriolar response has been shown to be intact or reduced.3-7 Many morphological, functional, and biochemical studies have reported the following changes in the malleolar skin microcirculation: Reduction in the number and structure of capillaries which are much dilated and coiled has been shown in areas with liposclerotic skin.8 Na-fluoroscence studies in these areas showed increased leakage in the pericapillary space.9 Destruction of the superficial lymphatic plexus,10 reduction in transcutaneous PO2,11-13 reduced fibrinolytic activity,14-16 extravasation and deposition of fibrin around the capillaries,17-19 activation of leukocytes and endothelial cells leading to degranulation and discharge of proteolytic enzymes and release of free radicals that damage the capillary wall20-21 have also been demonstrated in patients with severe CVI. A recent report found that patients of the CEAP classes 4 and 5 had significant increase in the number of mast cells in the immediate perivascular space in both the gaiter and thigh areas compared to controls.22 Macrophages were increased significantly in these areas only in patients belonging to classes 5 and 6.

Since the changes in the microcirculation are distinct from the class 4 and up, and because no apparent differences have been shown among classes 4 through 6 (apart from the skin blood cell flux), it is not surprising that healing of the ulcers did not improve the local hemodynamic functions as measured. Further, the sample size of the study was small but more importantly no mention was made as to how the ulcers were healed. It seems that the patients were treated conservatively and thus the cause of the ulcer - local venous hypertension - was still present when the ulcers were healed. On the other hand, if surgery was performed to correct venous reflux, the influence on healing might have been different in those patients with short refilling times. 6828b

REFERENCES

1. Cheatle TR, Shami SK, Stibe E, et al. Vasomotion in venous disease. J Royal Soc Med 1991; 84:261-63.

2. Belcaro G, Christopoulos DC, Nicolaides AN. Skin flow and swelling in postphlebitic lmbs. VASA 1989; 18:136.

3. Labropoulos N. Lower limb haemodynamics in chronic venous dysfunction. Ph.D. Thesis, Senate House, University of London, Jan 1995.

4. Allen AJ, Wright II D, McCollumn CN, Tooke JE. Impaired postural vasoconstriction: A contributory cause of edema in patients with CVI. Phlebology 1988; 3:163-68.

5. Belcaro G. Blood flow in the perimalleolar skin in relation to posture in patients with venous hypertension. Ann Vasc Surg 1989; 1:5-7.

6. Leu AJ, Franzeck UK, B�llinger A. Microangiopathies in chronic venous insufficiency. Therm Umsch 1991; 48:715-21.

7. Shami SK, Scurr JH, Coleridge-Smith PD. The venoarteriolar reflux in venous disease. Phlebology 1992; 7:127.

8. Fagrell B. Local microcirculation in chronic venous incompetence and leg ulcers. Vasc Surg 1979; 13:217-25.

9. Fagrell B. Microcirculatory disturbances: The final cause for venous leg ulcers? VASA 1982; 11:101-03.

10. Bollinger A, Isenring G, Franzeck UK. Lymphatic microangiopathy: A complication of severe chronic venous incompetence. Lymphology 1982; 15:60-65.

11. Franzeck UK, B�llinger A, Huch R, Huch A. Transcutaneous oxygen tension and capillary morphologic characteristics and density in patients with chronic venous incompetece. Circ 1984; 70:806-11.

12. Clyne CAC, Ramsden WH, Chant ADB, et al. Oxygen tension on the skin of the gaiter area of limbs with venous disease. Br J Surg 1985; 72:644-47.

13. Mannarino E, Pasqualini L, Maragoni G, et al. Chronic venous incompetence and transcutaneous oxygen pressure: A controlled study. VASA 1988; 17:159-61.

14. Browse NL, Gray L, Jarrett PEM, et al. Blood and vein wall fibrinolytic activity in healthy and vascular disease. Br Med J 1977; 1:478-81.

15. Wolfe JHN, Morland M, Browse NL. The fibrinolytic activity of varicose veins. Br J Surg 1979; 66:185-87.

16. Leach RD, Browse NL. The clearance of 125I-labeled fibrin from the subcutaneous tissue of limbs with lipodermatosclerosis. Br J Surg 1986; 73:465-68.

17. Browse NL, Burnand KG. The cause of venous ulceration. Lancet 1982; ii:243-45.

18. Burnand KG, Whimster I, Naidoo A, et al. Pericapillary fibrin in the ulcer-bearing skin of the leg: The cause of lipodermatosclerosis and venous ulceration. Br Med J 1982; 285:1071-72.

19. Falanga V, Moosa HH, Nemeth AJ, et al. Dermal capillary fibrin in venous disease and venous ulceration. Arch Dermatol 1987; 123:620-23.

20. Thomas PRS, Nash GB, Dormandy DA. White cell accumulation in dependent legs of patients with venous hypertension: A possible mechanism for trophic changes in the skin. Br Med J 1988; 296:1693-95.

21. Coleridge-Smith PD, Thomas P, Scurr JH, et al. Causes of venous ulceration: A new hypothesis. Br Med J 1988; 296:1726-27.

22. Pappas PJ, DeFouw DO, Duran WN, et al. Morphometric assessment of dermal venous microcirculation in patients with chronic venous insufficiency. Presented at 9th Annual Mtg, American Venous Forum, San Antonio, Texas, Feb 20-23, 1997.

TIME FOR A CHANGE

Editorial by John J. Bergan, M.D.

A number of changes in diagnosis and therapy of venous disorders have been reported in the pages of the Venous Digest since its founding. Among these is the trend towards ambulatory phlebectomy and away from sclerotherapy for major varicose clusters and the performance of subfascial endoscopic perforator vein interruption using video endoscopic techniques. However, no therapeutic change will make greater impact on patient care and on cost of treatment of venous disease than the accepted trend towards outpatient treatment of deep venous thrombosis.

Until now, standard anticoagulant therapy for venous thromboembolic disease has been a combination of parenteral heparin and oral warfarin. Now, the availability of low-molecular-weight heparins and proof of their efficacy and safety promises to change standard practice. Fractionated heparins now available have a mean molecular weight ranging from 4000 to 5000 daltons. This is approximately one-third the molecular weight for unfractionated heparins. The fractionated heparins preferentially neutralize activated factor X which is a key factor in the promotion of thrombin generation. At this time, there is a substantial literature on the clinical use of fractionated heparin as first-line treatment of patients with even proximal iliofemoral venous thrombosis.

A general demand for evidence-based medicine has produced five clinical trials on this subject. Each is a large, blinded, and randomized trial. Each has compared fractionated heparin given subcutaneously once or twice daily without any monitoring of partial thromboplastin time with intravenous standard unfractionated heparin using stringent aPTT monitoring in treatment of deep vein thrombosis.1 Outcome measures including recurrent venous thromboembolism and death have been analyzed. A meta-analysis of these trials has shown superiority of low-molecular-weight heparins over unfractionated heparin in a statistically significant fashion. Other studies which focused on major bleeding during fractionated heparin therapy have also shown fractionated heparin to be superior to standard heparin in this respect.

Now there is potential for use of fractionated heparin in the outpatient setting. Two large independent trials have addressed this issue and have shown that fractionated heparin used at home is effective and safe.2,3 The conclusion of the latter article states that "in patients with proximal vein thrombosis, treatment with low-molecular-weight heparin at home is feasible, effective, and safe."

Currently, there are three fractionated heparins available for use in this country. There is once-daily dalteparin sodium (Fragmin) supplied as 2500 units and 5000 units available as single-dose, pre-filled syringes. Another is ardeparin sodium (Normiflo) and a third is enoxaparin (Lovenox). Their availability and the previous proof of safety and efficacy will go far towards standardization of outpatient treatment of venous thromboembolic disease. This in turn will result in equal safety and efficacy to present treatment. A much lower cost in actual dollars and a marked improvement in convenience for patients is anticipated. 6861b

REFERENCES

1. Lensing AWA, Prins MH, Davidson BL, Hirsh J. Treatment of deep venous thrombosis with low-molecular-weight heparins: A meta-analysis. Arch Intern Med 1995; 155:601-7.

2. Levine M, Gent M, Hirsh J, et al. A comparison of low-molecular-weight heparins administered primarily at home with unfractionated heparin administered in the hospital for proximal deep vein thrombosis. N Engl J Med 1996; 334:677-81.

3. Koopman MMW, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. N Engl J Med 1996; 334:682-7.

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

Modern-Day Treatment of Acute Deep Venous Thrombosis
Comerota AJ.
Aust NZ J Surg 1995; 65:773-79

In this personal review, Dr. Comerota emphasizes the importance of adequacy of anticoagulant treatment and reemphasizes the importance of thrombolysis. He feels that lysis of deep venous thrombi does preserve venous valve function and points out the reasons why some patients fail to respond to thrombolytic therapy. Lastly, he details specific treatment strategies for acute deep venous thrombosis.

Prophylaxie des Thromboses Veineuses Postop�ratoires: Recommandations de l'assistance Publique-Hopitaux de Paris (Prophylaxis of Postoperative Venous Thrombosis: Recommendations of L'Assistance Publique H�pitaux de Paris)
Comit� Scientifique Thrombose de L'AP-HP
STV 1995; 7:119-20

This very important article was identified by Venous Digest contributing editor, Jean-Jerome Guex. It details recommendations for preventing deep venous thrombosis in general surgery, including surgery of the digestive tract, urologic surgery, orthopedic surgery, and gynecology. The detailed format of the recommendations could serve as a model for further recommendations, and a view of the original article would be of great service to physicians and surgeons in the United States.

D-Dimer Testing and Acute Venous Thromboembolism: A Shortcut to Accurate Diagnosis?
Becker DM, Philbrick JT, Bachhuber TL, Humphries JE
Arch Intern Med 1996; 156:939-46

This is a systemic review of the English literature comparing D-dimer testing to the results of other tests for deep venous thrombosis and pulmonary embolism. The authors conclude that the clinical utility of this potentially important test remains unproved.

Diagnosis and Surgical Aspects of Congenital Venous Angiodysplasia in the Extremities
Paes E, Vollmar J
Phlebology 1995; 10:160-64

A very large experience with 83 patients with angiodysplasia of the Klippel-Trenaunay type is reported. The triad of limb giantism, varicose veins, and birthmark was used for diagnosis, and malformations of the deep venous system were present in 96%. The Servell-Martorell syndrome was the assigned diagnosis in 34 cases in which there was a growth retardation in the affected extremity. All of these patients had deep venous system malformations. Among the abnormalities detected were absence of deep venous valves, persistent marginal vein, and, more rarely, aneurysm transformation.