VD709R

THE ROLE OF SCLEROTHERAPY IN ABNORMAL VARICOSE HAND VEINS
Duffy DM, Garcia C, Clark RE
Plast Reconst Surg 1999; 104:1474-79

ABSTRACT AND COMMENTARY BY:
John R. Pfeifer, MD
Professor of Surgery
Director, Division of Venous Disease
University of Michigan School of Medicine
Troy, Michigan

In this presentation, Dr. Duffy and his coworkers report their experience with the role of sclerotherapy in hand veins. There are few reports on management of varicose veins in the upper extremity. In the 11 years of this study, the authors treated thousands of patients with varicose veins but treated only 100 patients with varicose veins of the upper extremity during the same period. This may be an indication of the selection process used by the authors in identifying cases for treatment. Some physicians consider dilated veins of the dorsum of the hand to be normal. However, these unsightly, dilated, and tortuous veins fulfill the definition of varicose veins.

The 100 patients treated in this 11-year period ranged in age from 35 to 78 years. Injected veins ranged in size from 1 to 6 mm in diameter. Both aethoxysklerol and sodium tetradecyl sulfate were used as sclerosing agents. Two concentrations were compared. In the group treated with lower concentrations (0.5 STD and 1.5% aethoxysklerol), vein sclerosing was largely unsuccessful. In the group using higher concentration (3% aethoxysklerol only), there was a 95% disappearance rate in veins up to 5 mm in diameter. The authors observed that hand varicose veins required a higher concentration of sclerosant and a greater number of treatments than similar veins in the lower extremity.

Complications cited showed a different pattern from those seen in lower extremity sclerotherapy. Post injection thrombosis of hand veins occurred in 95% of injections when successful vein ablation was observed. This complication is more rare in lower extremity sclerotherapy. Hand edema (lasting less than ten days) occurred in 82% of patients with severe edema in 7.5%. Moderate discomfort in patients with thrombi (50%) was seen with both high and low concentrations of sclerosant. Severe discomfort (24%) was seen more often with high-concentration sclerosant. Post injection pigmentation, seen in lower extremity injection, was not observed in this series. Mild neovascularization was not seen in the low-concentration group but it was observed in 14% of the high-concentration group.

One alarming complication occurred in a single patient who developed blanching of the thumb, index, and middle finger after injection of a 2 mm vein in the thenar area using 3% aethoxysklerol. The vasospasm disappeared in ten minutes but the numbness and paresthesia persisted for two weeks. The authors suggest that extravasated sclerosant may have induced a neurapraxia of the sensory branch of the radial nerve where the cutaneous branches lie in the superficial tissue on the dorsoradial side of the hand. The authors report a case resulting in a lawsuit where a physician (independent of this study) carried out injection of a superficial hand vein which resulted in erythema, persistent edema, and carpal tunnel syndrome.

Despite these problems, the authors report a high success rate in the management of varicose veins of the dorsum of the hand. They conclude that these veins can be safely and effectively ablated in carefully selected patients.

COMMENTARY

This series is important and informative and involves an anatomic area of sclerotherapy which is poorly understood and not well documented in the literature. Dr. Duffy is a leader in this field and has a large personal experience with sclerotherapy. His observations must be noted by all of us.

In the preamble and in the conclusions of this study, the authors report that varicose veins of the hand can be treated as safely as lower extremity varicose veins. However, their reported incidence of post injection thrombosis (95% in successful injection) is high. This apparently had no effect on the final results. In addition, the reported incidence of severe discomfort is higher than is seen in injection of lower extremity varicose veins.

The incidence of neovascularization is higher than lower extremity injections. The absence of pigmentation is interesting and makes one wonder if the hydraulic system of the lower extremity is a major contributor to this troubling complication of lower extremity injection. The single case of paresthesia and numbness is an alarming but temporary problem.

All of these complications suggest that injection of the dorsal veins of the hand should be reserved for skilled and experienced sclerotherapists. This report gives us valuable information to use in discussion with patients who request this type of injection.

Finally, as one of the participants in the multicenter aethoxysklerol trial, I must remind the reader that the results are still under study by the Federal Drug Administration (FDA). They have stated that anyone using aethoxysklerol before it is officially approved faces loss of licensure (three physicians have already lost their license). There are one or two specialized exceptions to this rule of which I am sure the authors are aware. However, the average sclerotherapist must wait for final approval from the FDA before using aethoxysklerol.

I commend the authors for publication of this paper, a major contribution to sclerotherapy literature. vcpfe235

SENSORY IMPAIRMENT: A FEATURE OF CHRONIC VENOUS INSUFFICIENCY
Padberg FT, Maniker AH, Carmel G, Pappas PJ, Silva Jr MB, Hobson II RW
J Vasc Surg 1999; 30:836-43

ABSTRACT AND COMMENTARY BY:
Peter Gloviczki, MD
Professor & Chair, Division of Vascular Surgery
Mayo Clinic Rochester
Rochester, Minnesota

Chronic venous disease continues to receive little attention in the vascular surgery literature. Therefore, it is welcome that the Journal of Vascular Surgery continues to publish a large proportion of the manuscripts presented at the American Venous Forum meetings.

One of the excellent papers presented at the 11th annual meeting came from the Newark group headed by Robert Hobson who has developed a school of treatment of venous disease. Frank Padberg has tackled the difficult problem of sensory nerve impairment in chronic venous insufficiency. Peripheral neuropathy in patients with advanced severe chronic venous insufficiency is a significant problem and its distribution coincides with trophic skin changes. This is significant since the lack of sensation contributes to ulcer formation in areas exposed to even minor trauma.

The authors studied 23 limbs in 14 patients with chronic venous insufficiency of different severity. Patients with diabetes and previous surgical treatment on the affected extremity were correctly excluded. Sensory and motor assessment of the limbs was performed by a neurosurgeon. Sensory thresholds were determined at multiple areas on the affected limbs. Patients with more severe chronic venous insufficiency had more advanced sensory abnormalities. These sensory changes did not coincide with specific dermatomal or cutaneous nerve distributions.

COMMENTARY

Much needs to be learned about the specific reasons why some patients with a venous ulcer have excruciating pain. Sometimes the chronic pain syndrome they develop is much more severe than one would expect from the size of the ulcer. Fortunately, most patients have less pain and the sensory neuropathy itself is less disabling.

The sensory, motor, and sympathetic nerve function in patients with chronic venous insufficiency needs much more research. Frequently, when perforating veins are interrupted, the small nerves encountered are divided together with the veins. The consequence of this is unknown. It is conceivable that severe sensory neuropathy aggravates ulcer development in these patients. Indeed, the appearance of some distal venous ulcers resembles those seen in primary sensory neuropathy, neurotrophic ulcers, and diabetic peripheral neuropathy.

This is an important paper and we recommend it to all those who treat patients with advanced chronic venous disease. vcglo236

PRIMARY LOWER LIMB VARICOSITIES ARISING DIRECTLY FROM NORMAL DEEP VENOUS SYSTEMS: A SERIES REPORT
Olapade-Olaopa EO, Foy DM, Dikko BU, Darke SG
Ann Vasc Surg 2000; 14:166-69

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

This paper discusses a series of 52 patients with reflux in superficial veins. Selections were made from 450 consecutive patients with primary varicose veins referred over a one-year period. Clinical examination and continuous-wave Doppler were used to exclude greater and lesser saphenous vein incompetence. Subsequently, duplex scanning was performed to identify patterns of venous reflux.

It was shown that 17 patients had reflux in superficial venous tributaries without involvement of the saphenous vein and its tributaries. In 12 limbs, the incompetent tributaries arose from the groin while the remaining 5 had direct connections with the superficial femoral vein (n = 3) and the deep femoral vein (n = 2). In all cases, the deep veins were normal. When compared to duplex scanning, the continuous-wave Doppler had a specificity of 90%; however, it also had a low sensitivity of 60% and a positive predictive value of 67%.

COMMENTARY

It is now recognized that reflux may arise from most segments of lower extremity veins. In a recent paper from our institution, it was shown that primary venous reflux begins in the superficial veins and their tributaries without deep or perforator vein incompetence.1 It was also shown that progressive reflux may be an ascending process in addition to retrograde development. In another recent paper from our center, we identified 84 limbs (62 patients) with primary superficial vein reflux and competent saphenous trunks.2 The prevalence of such reflux was 9.7% (84/860). Reflux in non-saphenous tributaries was identified in only 15 limbs (1.7%). The prevalence of non-saphenous tributary reflux was comparable to that in the current study (5/540, 1.1%).

The findings of this paper support evidence from other reports.1-8 The inadequacy of clinical examination and continuous-wave Doppler evaluation in this group of patients was shown clearly and is in agreement with previous studies.1,2 In order to tailor treatment for each patient with superficial reflux, examination with duplex scanning is essential. Duplex study will prevent unnecessary ligation and/or stripping of the saphenous veins. Treatment will be limited to the incompetent veins.

Taking into account the authors' concern about cost of duplex scanning and its use in diagnosing patterns of reflux in patients with primary disease, I still believe its use is appropriate. The senior author of this study demonstrated that continuous-wave Doppler was adequate for detecting greater saphenous vein reflux, missing only 4/87 limbs. However, this method was clearly inadequate in the popliteal fossa. In an earlier study of 136 patients, continuous-wave Doppler detected 73% of limbs with greater saphenous vein reflux and only 33% of limbs with lesser saphenous vein reflux.10

REFERENCES

1. Labropoulos N, Giannoukas AD, Delis K et al. Where does venous reflux start? J Vasc Surg 1997; 76:736-42.

2. Labropoulos N, Kang SS, Mansour MA. Primary superficial vein reflux with competent saphenous trunk. Eur J Vasc Endovasc Surg 1999; 18:201-06.

3. Cotton LT. Varicose veins: Gross anatomy and development. Br J Surg 1961; 48:589-98.

4. Dodd H. Varicosity of the external and pseudo-varicosity of the short (external) saphenous vein. Br J Surg 1960; 47:520-30.

5. Labropoulos N, Delis KT, Nicolaides AN. Venous reflux in symptom-free vascular surgeons. J Vasc Surg 1995; 22:150-54.

6. Labropoulos N, Belcaro G, Giannoukas AD, et al. Can the main trunk of the greater saphenous vein be spared in patients with varicose veins? Vasc Surg 1997; 31:531-34.

7. Zamboni P, Cappelli M, Marcellino MG, Murgia AP, Pisano L, Fabi P. Does a varicose saphenous vein exist? Phlebology 1997; 12:74-77.

8. Labropoulos N, Delis K, Mansour MA et al. Prevalence and clinical significance of posterolateral thigh perforator vein incompetence. J Vasc Surg 1997; 26:743-48.

9. Darke SG, Vetrievel S, Foy DMA, Smith S, Baker S. A comparison of duples scanning and continuous-wave Doppler in the assessment of primary and uncomplicated varicose veins. Eur J Vasc Endovasc Surgery 1997; 14:457-61.

10. McMullin GM, Coleridge Smith PD. An evaluation of Doppler ultrasound and photoplethysmography in the investigation of venous insufficiency. Aust NZ J Surg 1992; 62:270-75.

THE PHYSIOLOGICAL EFFECT OF GRADED COMPRESSION STOCKINGS ON BLOOD FLOW IN THE LOWER LIMB: AN ASSESSMENT WITH COLOUR DOPPLER ULTRASOUND
Benko T, Kalik I, Chetty MN
Phlebology 1999; 14:17-20

COMMENTARY BY:
Neil S. Sadick, MD, FACP
New York, New York

This report summarizes a controlled study comparing thigh-high or knee-high graduated support stockings and their role in decreasing femoral and popliteal vein diameters. The authors were British-hospital-based and the studies using color flow Doppler were performed in the department of radiology. In addition to measurements of femoral and popliteal vein diameter, peak venous blood flow velocity in the femoral vein was assessed.

The results of this study were that only thigh-high stockings increased peak blood flow velocity in the femoral vein and it was only these stockings that decreased the cross-sectional area within the popliteal vein. No such effect was seen with knee-high support stockings.

The implications of the study are important to the practicing phlebologist. If the results of this study are taken at face value, then only thigh-length graduated support hose decrease deep venous diameters and increase femoral blood flow velocity. One must take the results of this study and balance them against common knowledge that thigh-high stockings are worn with lesser compliance than below-knee stockings. vdsad195

THE EFFECT OF COMPRESSION THERAPY ON VENOUS HAEMODYNAMICS IN PREGNANT WOMEN
B¸chtemann AS, Steins A, Volkert B, Hahn M, Klyscz T, J¸nger M
Br J Obste Gynec 1999; 106:563-569

ABSTRACT AND COMMENTARY BY:
Jeffrey L. Ballard, MD, FACS
Associate Professor of Surgery
Loma Linda University Medical Center
Division of Vascular Surgery
Loma Linda, California

The lower extremities of 15 pregnant women with no clinical or Doppler ultrasound evidence of chronic venous insufficiency were studied using strain-gauge plethysmography and duplex ultrasonography to determine the direct influence of graduated compression stockings on lower extremity venous hemodynamics at different stages of gestation. Seven women were in their first pregnancy while the others were multiparous. Examination was performed in the 20th and 36th gestational weeks, and then 4 to 5 weeks postpartum. All measurements were performed with and without pantyhose-type graduated compression stockings (Jobst medical legwear, Jobst, Germany).

The study demonstrated improvement in all aspects of measured venous hemodynamics with application of graduated compression stockings at different stages of gestation. Specifically, calf muscle pump function improved and venous refill time lengthened significantly with compression. This lengthening in venous refill time is considered equivalent to a decrease in overall deep venous reflux. Interestingly, there was no statistically significant difference detected between the left and right lower extremities with respect to calf muscle pump function or venous refill time.

Graduated compression stockings were associated with a significant acceleration of mean blood flow through the femoral vein. However, there was no significant difference between measurements at 20 and 36 weeks' gestation. As expected, mean diameter of the femoral vein increased in the latter stage of pregnancy and returned to baseline levels in the postpartum period. Finally, all subjective symptoms of chronic venous insufficiency improved with graduated compression stockings.

COMMENTARY

These authors are to be congratulated for performing a well-controlled study with no patient lost to followup. Their findings that graduated compression stockings improve clinical symptoms of venous congestion and that overall venous hemodynamics of the lower extremities during pregnancy and in the early postpartum period were improved are consistent with other studies measuring alterations in lower extremity venous hemodynamics associated with normal pregnancy. The fact that there was no statistically significant difference between the right and left lower extremities underscores the fact that lower extremity venous congestion occurring in pregnancy is not due to outflow obstruction of the left iliac vein caused by compression of the right iliac artery by the gravid uterus.

Alterations in venous hemodynamics demonstrated in this study are likely related to venous dilation and increase in venous capacitance secondary to hormonally influenced smooth muscle relaxation. Whether or not these positive changes in venous hemodynamics translate into decreased incidence of thrombotic events associated with pregnancy remains to be determined.

This study clearly demonstrates that graduated compression stockings, although warm and sometimes unbearable, are beneficial and should be a mainstay for relief of symptoms of chronic venous insufficiency during pregnancy and the postpartum period. vdbal236

Compression Therapy of the Extremities
AUTHORS: Partsch H, Rabe E, Stemmer R
PUBLISHER: Editions Phlebologiques Francaises, Paris, 2000
PREFACE BY: J. L. Villavicencio, MD
TRANSLATION BY: Ulrike Trostmann

REVIEW BY:
John J. Bergan, MD, FACS
La Jolla, California

Compression treatment is the keystone in the arch that makes up the many-faceted treatment of severe chronic venous insufficiency and lymphedema. Yet, most physicians who care for these conditions know little of the scientific background which has led to today's available technology. The authors of this work set out an ambitious objective in producing this volume. This was to present a universal description of compression therapy and patient mobilization, taking into consideration all theoretical, experimental, and clinical knowledge. Well, ambitious or not, they did it.

This is a heavyweight volume in excess of 380 pages, printed in a large format with a very small typeface and almost miniature illustrations. It is hard to imagine that anything dealing with limb compression has been left out. We would expect to find a section on compression stockings and that is here. Also, one would expect a section on bandages and bandaging techniques and that is included. There is even a section on compression using mechanical devices, including the mercury chamber, intermittent pneumatic compression, and even compression of the plantar venous plexus. Did you know that that plexus was named for the French anatomist, Lejars?

In the historical overview, we are presented photographs of mural paintings in the Tassili caves (Sahara), one of which shows left lower extremity lymphedema and while another shows compression bandaging for below-knee edema.

Although the organization of the volume is entirely predictable, it was the method of referencing that caught this reviewer's attention. In addition to conventional author, title, and reference, we are provided with the number of citations in the literature as well as number of citations originating with the authors. Finally, we are given a one- or two-sentence summary of the contents of each article. As many are written in French, German, and other languages, the English summary is of great value. There is a profusion of references. One chapter, at random, has 219 references; another 410.

If that is not enough to pique your curiosity, look at Chapter 10 entitled Strategy . This describes a variety of diseases and conditions which can be treated with compression. Within this chapter are pictograms drawn by Robert Stemmer which make it possible to understand the treatment for each of the listed conditions without reading the text. After seeing more than 30 conditions dealt with in this chapter on strategy, one wonders whether there is anything in medicine that cannot be treated by compression therapy.

This is a classic volume which should be on the library shelves of every vascular center which seeks to integrate surgical, medical, and endovascular treatment of vascular diseases and conditions.

SURGICAL VENOUS THROMBECTOMY
Juhan C, Alimi Y, Di Mauro P, Hartung O.
Cardiovasc Surg 1999; 7:586-90

COMMENTARY BY:
Kenneth Myers, MS, FACS, FRACS
Vascular Surgeon
Monash Medical Centre & Epworth Hospital
Melbourne, Australia

The authors have clearly summarized the expected outcome and indications for surgical thrombectomy for deep venous thrombosis, drawing heavily on results from the well-known Swedish study and their own experience. They argue that successful thrombectomy will preserve valve function in the treated segment and will also prevent secondary valvular incompetence otherwise resulting from distention of adjacent venous segments. In contrast, they review evidence that conservative treatment with anticoagulation will lead to recanalization with valve destruction or failure of recanalization with venous obstruction in many patients, causing late sequelae from venous hypertension, particularly for iliac or extensive four-vessel thrombosis.

The authors also review the rather limited published experience for thrombolysis and concentrate more on contemporary results for thrombectomy. They consider that operative mortality should be no more than 0.4% and that patients undergo duplex scanning and abdominopelvic CT scanning with intravenous contrast. They favor operations for patients with iliofemoral or iliocaval thrombosis but not for isolated femoropopliteal thrombosis. They reserve operation for thrombosis up to seven days old. They reject patients in whom thrombosis is due to associated pelvic inflammatory or malignant disease, coagulopathies, or recurrent venous thrombosis. Particular indications include iliofemoral iliocaval thrombosis during pregnancy, propagation from ovarian or long saphenous vein thrombosis, or complications of an inferior vena caval filter.

Finally, the authors state that less than 25% of lower limb deep vein thromboses are suitable for thrombectomy. In spite of longstanding enthusiasm by some surgeons, they correctly point out that "few centers still routinely perform this procedure."

COMMENTARY

The authors properly refer to reasons why venous thrombectomy has not gained more widespread acceptance. Conservative treatment with anticoagulants is becoming progressively more simple with good evidence of that low-molecular-weight heparin (LMWH) provides excellent early control to limit propagation,1 that LMWH is probably preferable to warfarin over the ensuing period to reduce risk of recurrence,2 and that outpatient treatment with early ambulation is feasible, safe, and possibly preferable to inpatient treatment.3 All of these factors lead to early return to normal activities. Alternatively, thrombolysis or thrombectomy require a lengthy hospital stay, attendant morbidity and mortality (admittedly small), and disruption of activities.

Thus, the only major advantage for surgical thrombectomy is reduction in risk of postthrombotic sequelae. The comparative risk stated in the only published series by Plate et al.,4 is summarized in the present article. The risk of symptoms, abnormal venous function, or complications is approximately twice as great for conservative treatment than for surgery. However, the actual incidence of leg ulceration at ten years is stated to be 17% for conservative treatment and 8% for surgery. Approximately 50% of patients treated with anticoagulation do not develop any symptoms. Therefore, disability usually does not become apparent for several years, if at all. In addition, the major complication of ulceration is still possible and may not be avoided by surgery. Thus, it is not surprising that many patients and their treating physicians opt for expedient early conservative management.

It appears that many surgeons consider surgery only for desperate circumstances such as phlegmasia cerulea dolens. I suspect that similar reservations will apply to the extended use of thrombolysis for deep vein thrombosis. ivdfmye2

REFERENCES

1. Hull RD, Raskob GE, Brant RF, et al. Low-molecular-weight heparin versus heparin in the treatment of patients with pulmonary embolism. American-Canadian Thrombosis Study Group. Arch Intern Med 2000; 24:229-36.

2. Gonzalez-Fajardo JA, Arreba E et al. Venographic comparison of subcutaneous low-molecular-weight heparin with oral anticoagulation therapy in the long-term treatment of deep vein thrombosis. J Vasc Surg 1999; 30:283-92.

3. Partsch H, Kechavarz B, Kohn H, Mostbeck A. The effect of mobilization of patients during treatment of thromboembolic disorders with low-molecular-weight heparin. Int Angiol 1997; 16:189-92.

4. Plate G, Eklof B, Norgren L et al. Venous thrombectomy for iliofemoral vein thrombosis: Ten-year results of a prospective randomized study. Eur J Vasc Endovasc Surg 1997; 14:367-74.

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

A Simple Clinical Classification of Lymphedema
Bruna J, Miller AJ, Beninson J.
Eur J Plast Surg 1999; 22:404-05

The authors, all experienced in investigations in lymphedema, present a new classification based on inspection, palpation, the effects of limb elevation, and the functional status of the extremity. The classification appears to be clinically descriptive but not informative with regard to treatment.

Leg Cramps in the Elderly: Prevalence, Drug and Disease Associations
Abdulla AJJ, Jones PW, Pearce VR
Int J Clin Pract 1999; 53(7):494-96

This study identifies a prevalence of leg cramps at 50%. These are more common in women than men and occur most often at night. They were strongly associated with peripheral vascular disease and arthritis but negatively associated with heart failure, hypertension, diabetes, and stroke. Unfortunately, peripheral vascular disease was not separated as to arterial or venous. Readers of the Venous Digest, of course, know that leg cramps are associated with venous insufficiency.