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Introduction Although rare, nonthrombotic causes of venous obstruction do occur. Their ultrasound findings can mimic deep vein thrombosis (DVT). We sought to examine the ultrasound appearance of these tumors to determine whether their differentiation from DVT was possible. Case Report Two patients, in whom a DVT was initially suspected, were subsequently diagnosed with intravascular tumors: a leiomyosarcoma and a hemangioma. The first patient presented with thigh pain, and an initial diagnosis of long saphenous vein (LSV) and common femoral vein thrombosis was made. The apparent thrombus remained unchanged despite anticoagulation. Proliferation of the lesion outside of the LSV developed, resulting in a review of the diagnosis, and surgical resection was performed. A histological diagnosis of leiomyosarcoma was made. The second patient presented with leg swelling and an initial diagnosis of External Iliac vein thrombosis was made. Further ultrasound assessments demonstrated arterialized flow within the lesion and surgical resection was performed, with a histological diagnosis of intravascular epithelioid hemangioma. Results The B-mode appearance was similar for both. The presence of arterialized flow within the lesions is helpful but may not be diagnostic because of recent reports that neovascularization may develop within thrombus. Conclusion Suspicion needs to be raised in a patient presenting with an unprovoked DVT or when conventional treatment does not result in improvement of symptoms; as well as when prolonged arterialization is identified within the thrombus. These signs can alert the clinician to a possible non-thrombotic mechanism of venous obstruction.

Objective Damage to the saphenous nerve (SN) has been a known complication during varicose vein surgeries. We tested whether a better knowledge of the anatomy of the SN and the great saphenous vein (GSV) can prevent such damage. Methods We conducted a morphological and histological examination on 86 limbs from 43 cadavers in order to analyse the anatomical interrelation between the SN and the GSV in the lower leg and we also measured the distance between the nerve and the vein in a sample of 42 sections from three parts of the lower leg. Results The anatomical relationship between the SN and the GSV is varied and the two structures run close to each other so a better knowledge of their anatomy in itself proved insufficient in preventing damage to the SN. Conclusion However, in the case of endovenous laser therapy and radiofrequency ablation tumescent anaesthesia decreases the risk of damage to the SN.

Oxidative stress can lead to vein graft dysfunction in the saphenous vein. This ex vivo study is aimed to compare the effects of increasing concentrations of the antioxidant N-acetylcysteine (NAC) with heparinized saline (HS) on endothelial and smooth muscle function in the human saphenous vein. Long saphenous vein segment obtained during infrainguinal bypass surgery was divided into 7 rings; 1 immersed in HS and the remaining 6 in increasing NAC concentrations (0.0025%, 0.005%, 0.01%, 0.02%, 0.03%, and 0.04%). Rings were mounted in an organ bath, and relaxant responses to acetylcholine and sodium nitroprusside were assessed through isometric tension studies. Endothelium-dependent relaxations were observed in 77 vein segments from 11 patients. No significant difference was seen in veins treated with either lower NAC concentrations (0.0025%, 0.005%, 0.01%, 0.02%, and 0.03%) or HS. However, HS-treated veins showed significantly better relaxation compared to those treated with maximum (0.04%) NAC ( P < .05). Endothelium-independent relaxations were observed in 91 segments from 13 patients. No difference in relaxation was observed between veins treated with HS or any of the NAC concentrations. In conclusion, lower NAC concentrations do not offer better endothelial protection than HS, whereas the highest NAC concentration has a detrimental effect on endothelium-dependent relaxation. Moreover, NAC did not show beneficial effect on direct smooth muscle relaxation.

Objectives: To determine the change in long saphenous vein (LSV) area in early pregnancy and the reversal postpartum in comparison with non-pregnant control values. Methods: Ultrasonography was used to determine the LSV areas at four different levels in the right and left legs of women in an erect position. The measurements from 69 nulliparous women were used to determine the non-pregnant baseline measurements for vein area. The vein areas were similarly measured from 39 primigravida women in early pregnancy and postpartum. Results: There was no significant difference found between measurements obtained from the right and the left legs. Non-pregnant baseline measurements were less than either the early pregnancy, or postpartum measurements obtained from the primigravida women. Conclusions: Physiological changes associated with early pregnancy induce dilation of the LSV, and the reversal postpartum is not complete with vein areas statistically larger than in the non-pregnant state.

Poor rehabilitation rates and the high-cost of managing postamputation patients justify an aggressive revascularization policy in critical lower limb ischemia. Endovascular therapy is our first choice for limb salvage in these patients. However there are patients for whom endovascular therapy is not feasible. When bypass is necessary, autologous vein is a superior conduit to synthetic material. However, varicosities usually contraindicate autologous vein bypass because of the risk of aneurysm formation, rupture and increased intimal hyperplasia compared with nonvaricose venous grafts. We report the use of varicosed long saphenous vein (LSV) with external Dacron support in infrainguinal bypass procedures for limb salvage, where endovascular therapy was not feasible. The external Dacron tube was not brought close to the distal anastomotic area itself. With a mean follow-up of 18 months, duplex ultrasonography and computed tomography angiography showed no evidence of stenosis of the reinforced vein segments or aneurysmal degeneration of the residual vein. External reinforcement with Dacron prosthesis allows the use of autogenous greater saphenous veins with varicose dilatation without compromising graft patency and limb salvage.

Objective: Endovenous laser therapy (EVLT) is a new minimally invasive treatment for varicose veins employing laser ablation of the long saphenous vein (LSV) under tumescent local anaesthesia. Concerns about thermal injury to perivenous nerves (tibial, peroneal, sural) have prevented its use for saphenopopliteal/short saphenous incompetence. This study assesses heat dissipation around the LSV during EVLT. Methods: In 12 consenting patients undergoing EVLT (Local research ethics committee approved), thermocouples (inserted percutaneously) were positioned (ultrasound control) 3, 5 and 10 mm from the LSV following perivenous injection of tumescent anaesthesia (0.1% lignocaine at room temperature). The 810-nm diode laser delivery system delivered 1-s pulses (12 W power) with 1-s intervals during laser fibre withdrawal at 3 mm/s. Results: The maximum recorded temperatures at 3, 5 and 10 mm were 43.3°C, 42.0°C and 36.0°C, with median temperatures (±interquartile range) of 34.5°C (30.8–40.0), 33.7°C (30.5–39.9) and 31.1°C (30.3–33.3), respectively. Conclusions: Although intravascular laser-tip temperatures of up to 1334°C have been recorded in experimental models of EVLT, these results indicate that heat dissipation into adjacent tissues is minimal. Thus, careful ultrasound-guided injection of adequate volumes of perivenous local anaesthetic and the associated heat-sink effect should allow safe use of EVLT in treating saphenopopliteal/short saphenous incompetence.

Objectives: Clinical experience suggested that preoperative infiltration of proposed avulsion sites with bupivacaine and adrenaline reduced bleeding associated with varicose vein surgery. This hypothesis was subjected to a randomized controlled trial. Methods: Twenty patients undergoing bilateral long saphenous vein (LSV) stripping and avulsions were randomized to have one leg infiltrated with 0.25% bupivacaine and the other with 0.25% bupivacaine with adrenaline (1 in 200,000). Following induction of general anaesthesia, 10 mL of local anaesthetic was infiltrated into the groin and 20–30 mL over the marked varicosities down the leg. Bilateral PIN stripping and hook avulsions were performed. Operative blood loss was recorded for each leg and the area of strip-site and avulsion-site bruising was determined five days postoperatively. Results: There was no difference in the numbers of avulsions between the legs receiving adrenaline (median 12, range 4–23) and controls (median 13, range 4–25), but adrenaline significantly reduced the operative blood loss (median 41 mL, range 17–122) compared with control legs (median 79 mL, range 28–210; P < 0.001, Wilcoxon). There was also a significant reduction in postoperative avulsion-site bruising (median 45 cm2, range 13–101 compared with median 70 cm2, range 34–221; P < 0.001). There was a smaller reduction in strip-site bruising (median 50 cm2, range 14–128 compared with median 62 cm2, range 21–141; P < 0.001). Conclusions: Preoperative infiltration with bupivacaine and adrenaline is safe and reduces bleeding and bruising associated with varicose vein surgery.

Objective: The aim of this study was to reproduce the results of VNUS closure in our setting; to minimize the cost associated with the procedure; and to reduce the need for an experienced ultrasonographer during the procedure. Methods: Over a two-year period, 26 patients (42 limbs) were treated. A VNUS radio-frequency machine was used and assisted by intraoperative localization using Sonosite ultrasound, which was operated by the surgeon. All patients were treated under general anaesthetic. Nine patients were operated as a day case and 17 others stayed overnight. Median follow-up period was seven months. Results: The mean age of the patients was 37 years (range 19–69). Eighteen patients had primary and eight had recurrent varicose veins. Sixteen patients underwent bilateral and 10 underwent the unilateral procedure. Long saphenous vein (LSV) closure was performed in 41 limbs and short saphenous vein closure in two limbs. The LSV was accessed at the ankle in 36 and at knee in three limbs. In two other limbs, groin exploration with retrograde closure of the LSV was achieved. One patient developed numbness at phlebectomy site. None of the patients had deep vein thrombosis and all the treated veins were closed at the one-week scan. In bilateral cases, one catheter was used instead of two for closure in 12 of the 16 limbs. Using our approach, we were able to make a cost savings of £8,600.00. Conclusion: Technical success in radiofrequency vein closure can be achieved without the need for an additional ultrasonographer. We have shown that our approach is safe, effective and less expensive to deliver.

Clinical and sonographic findings of three octogenarian patients with recent-onset venous insufficiency with venous ulcer were evaluated with clinical examination and venous duplex scanning. The venous duplex findings in the affected lower limb of patients with right heart failure showed phasic flow in the long saphenous vein. The phasic flow was traced back up to the inferior vena cava and the hepatic veins. Echocardiogram confirmed marked tricuspid regurgitation. Clinically, a simple compression of the sapheno-femoral junction showed an absence of pulsation in the long saphenous veins, giving clinical confirmation that venous backflow caused the pulsation in the limb veins. Right heart failure in patients with late-onset venous insufficiency and venous ulcer should be suspected. Sonography complemented with clinical examination is the key to the proper evaluation and management of chronic venous insufficiency with right heart failure.

Objective: Trendelenburg tourniquet tests should determine long saphenous vein (LSV), short saphenous vein (SSV) or perforating vein incompetence. This study analyses the inter-observer variability of the Trendelenburg test and the results are compared with duplex scanning - the standard for venous incompetence analysis. Methods: A total of 54 legs of 43 patients with varicose veins were investigated (36 female and seven male patients; mean age 47 years [range: 17-75]). All legs were evaluated for valvular incompetence by Trendelenburg tourniquet tests performed by three different investigators. A duplex scan was also performed in all legs. The inter-observer variability of the tourniquet test was expressed in Kappa (κ Results: The inter-observer variability of the Trendelenburg test in detecting valvular incompetence of the LSV, SSV, perforating veins in the upper leg (PVU) and lower leg (PVL), expressed in Kappa, were: 0.39, 0.42, 0.14 and 0.49, respectively. The sensitivity of the tourniquet test in detecting valvular incompetence of the LSV, SSV, PVU and PVL, in relation to duplex scanning was: 50, 35, 52 and 35% respectively, and the specificity was 59, 72, 46 and 80%, respectively. Conclusions: The evaluation of patients with varicose veins with the Trendelenburg tourniquet test is unreliable and therefore obsolete. In order to manage patients with varicose veins properly duplex investigation is mandatory.

Objective: Primary varicose veins of the long saphenous vein and its tributaries were managed in 104 limbs of 101 patients with the assistance of endoscopic surgery. Methods: Patients were divided into four clinico-anatomical types according to normal veins involved in the varicosities. With good illumination and magnified monitor viewing by means of a surgical endoscope, the varicositic trunk, varicositic tributaries, incompetent perforating veins and healthy veins could be clearly visualized and identified. Through two or more access incisions (2.5-3.0 cm in length), the varicose veins were completely dissected, divided and removed. The incompetent perforating veins were clipped and divided. In all cases, the mean number of incisions in each limb was 3.0. Results: The most common cause of morbidity was maceration of the incision wound. Transient numbness may have presented at the dissected area, but there were no signs of injury to the saphenous nerve. Conclusions: There was very little possibility of recurrence, because no residual varicosities or incompetent perforating veins remained after this operation. Recurrence presented in only one case at follow up, three months postoperatively. Patients were satisfied with the minimal surgical scarring and complete absence of disfiguring varicosities in the limb.

Objective: Ultrasonography of the anatomical course of the long saphenous vein (LSV) and its tributaries to produce and verify an anatomical classification (five types). Methods: Four hundred and ninety-three limbs (293 healthy; 200 with varicose veins, VV) were investigated by ultrasonic duplex imaging by the two authors independently, identifying the LSV as the vessel in the (ultrasonic) saphenous fascial ‘eye’ compartment (SFEC), in the thigh, and within two fascial layers between tibia and medial gastrocnemius muscle, below the knee. Results: Type A: LSV runs entirely in the SFEC without relevant tributaries: overall (O) 112 (23%), limbs with vv (V) 13, normal limbs (N) 99. Type B: LSV runs in the SFEC with one or more relevant tributaries below the knee: O 133 (27%), V 70, N 63. Type C: LSV runs in the SFEC with a relevant tributary above the knee: O 89 (18%), V 28, N 61. Type D: LSV runs in the SFEC from the foot upwards, continuing at the middle third of the leg in a large side vein with the calibre and role of the LSV but in a more superficial location. LSV stem is absent (or hypoplasic) in the para-tibial position. At the thigh level the tributary re-enters the true LSV: O 72 (14.5%), V 42, N 30. type E: similar to type D but the LSV is absent only at the knee level: O 72 (14.5%), V 38, N 34. Unclassified: O 15 (3%), V 9, N 6. Conclusions: We found a good reproducibility and clinical utility of the suggested classification. Remarks: (a) the absence (or hypoplasia) of LSV at the knee level with prevalence of a tributary in almost 30% of the limbs is of importance for arterial bypass and saphenous sparing management; (b) there is a low rate of LSV complete incompetence (6%); (c) there is a correlation between absent LSV (or presence of a relevant tributary) and the incidence of VV.

Objective: To compare the postoperative morbidity of conventional stripping with inverting stripping of the long saphenous vein in a randomised prospective trial. Methods: One hundred and thirty-six patients with primary uncomplicated long saphenous vein incompetence were randomised to either conventional or inverting stripping of the long saphenous vein. Blood loss, operating time and length of vein stripped were measured intra-operatively. Number and size of haematomas, bruising and diameter of thethrombosed channel were assessed 1 week postoperatively by clinical examination and by duplex ultrasonography. Pain, mobility and analgesia consumption were noted in a daily diary for the postoperative week. Results: Blood loss was significantly lower in the inverting group than in the conventional group, with a median of 50 ml for the conventional group and 20 ml in the inverting group (pConclusions: Inverting stripping used less operating time and there was less blood loss perioperatively. There did not appear to be any further benefits to inverting stripping of the long saphenous vein during the early perioperative period.

Objective: To evaluate the impact of duplex ultrasonography on the treatment plan of patients with uncomplicated primary varicose veins. Methods: Forty-nine consecutive patients (62 legs) with primary uncomplicated varicose veins were examined clinically and with hand-held Doppler (HHD) and duplex ultrasonography in an outpatient clinic on the same day. The plans for subsequent treatment were recorded separately after the two ultrasound examinations. Results: The accuracy of the HHD examination was 0.71 in the saphenofemoral junction (SFJ) and long saphenous vein (LSV trunk). In fifty-six limbs (90%) duplex scanning did not affect the surgical treatment of the patients. Conclusions: Most operations on primary varicose veins can be performed on the basis of clinical and HHD examinations by an experienced surgeon. Duplex ultrasonography can be used selectively in the patients with suspected saphenopopliteal junction (SPJ) reflux or equivocal HHD findings.

In an attempt to reduce the morbidity of high tie and strip of the long saphenous vein various extraluminal and intraluminal electrosurgical devices have been employed in the past using monopolar energy to ablate varicose veins. As result of this full-thickness skin burns and saphenous nerve injuries were observed by surgeons using these techniques. This report describes the VNUS Closure, a novel endovascular computer-feedback-controlled application of bipolar electrothermal energy which ensures transmural heating of the vein wall while minimising thermal spread to neighbouring tissues.

Objective:To examine the effects of heparin on smooth muscle cells (SMCs) in explants of varicose, long saphenous vein (LSV).Procedures:Explants of varicose LSV were cultured for 7 days either alone, or with heparin at 10, 100 or 1000 IU/ml (Monoparin). At 7 days, cultured explants were analysed for changes in intimal and medial thickness and by immuno-histochemistry. Comparisons were made with explants at initial isolation and with similar, cultured explants of normal LSV.Results:In normal LSV, by day 7, SMC-derived neo-intimal hyperplasia developed ( pConclusions:The response to heparin in explants of varicose LSV is different from that of normal LSV, which is biphasic and complex.

Objective: To develop an in vitro model from explants of human varicose veins (VVs). Procedures: Segments of VVs were cultured for up to 14 days with 30% fetal calf serum. At 7 and 14 days, segments were analysed for changes in intima:media thickness and by immunohistochemistry. Comparisons were made with VVs at isolation and cultured explants of normal vein. Results: At isolation, VVs had a significantly thicker intima than normal veins ( pConclusions: Segments of VVs can be maintained in culture for up to 14 days without developing a neo-intima and may provide a suitable model to investigate mechanisms underlying the chronic venous insufficiency of varicosity.

The aim of this international multicenter trial was to evaluate the effects of a new surgical device (Gore External Valve Support-EVS) and technique for external valvuloplasty of the long saphenous vein (LSV). Patients with superficial venous disease and venous hyper tension due to pure superficial venous incompetence were randomized into two treatment groups, the first treated with "conventional treatment" (ligation or stripping) and the second with external valvuloplasty with the EVS. Patients with uncomplicated varicose veins within the age range of 35-65 years were included. Incompetence with presence of functional cusps at the saphenofemoral junction (SFJ), with vein dilatation were the main inclusion criteria. The EVS comprised of a GORE-TEX® patch material (including a nitinol frame) that is placed around the vein, producing a reduction in the caliber of the vein. Also the vein section becomes elliptical. These combined actions are aimed to reduce incompetence, allowing a better closure of the cusps. The EVS was placed at the SFJ after limited dissection of the vein and ligation of collaterals. The procedure was randomized as an alternative to simple ligation or stripping (according with the procedure commonly used in the center). The associated ligation of distal incom petent veins was allowed. The main outcome measures of the study were evaluated by color-duplex (morphologic findings and evaluation of reflux) and with ambulatory venous pressure (AVP) or air-plethysmography (APG). Main endpoints of the first year of the study and main subject of this report (mainly concerning safety within the first year of follow-up) were considered presence/absence of reflux; patency of the veins; mobility/function of vein cusps; occurrence of thrombosis; tolerability of the device; and increased complexity and operating time needed for the EVS. At 1 year 30 patients had been randomized (14 EVS implanted, 16 controls). Reflux was absent in all EVS patients, all treated veins were patent, and all cusps were mobile. No thrombosis had been observed and the tolerability of the device was very good. The increased complexity required by placing the EVS was limited (5-12 minutes more). In conclusion results of the first year show efficacy and tolerability of the EVS. In selected patients (superficial LSV incompetence, reflux-dilatation, functional SFJ cusps, incompetence mainly due to enlargement of the vein), the EVS could be an effective alternative to "destructive" ligation and/or stripping of the vein. Prolonged follow-up will indicate the clinical poten tials of the EVS.

Venous function measured by air-plethysmography (APG) was compared to anatomical patterns of reflux assessed by duplex scanning and associated clinical features in 253 limbs with recurrent varicose veins following previous superficial venous surgery. The results showed that a previous history of deep venous thrombosis, previous procedure with preservation of the long saphenous vein, and a history of healed ulcer or current ulcer were each associated with worse venous function. Patterns of reflux which included multiple sites of reflux and presence of deep incompetence were also associated with worse venous function. Where there was reflux in the groin, limbs with a wide recurrent saphenofemoral junction presented the worst venous filling time and venous filling index, whereas those with reflux unrelated to the common femoral vein had nearly normal venous physiology and occurred almost exclusively in females. The other patterns of recurrence in the groin were physiologically indistinguishable from each other. In conclusion, certain patterns of reflux, clinical and operative features are associated with worse venous physiology in limbs with recurrent varicose veins. These features of recurrence with more severe physiological disturbance may necessitate a higher priority for surgical intervention.

Objective: To evaluate the pathway of reflux in incompetent long saphenous veins (LSVs), paying particular attention to the role of longitudinal saphenous tributaries in the thigh (accessory saphenous veins, ASVs). Design: Prospective study in a group of patients with primary varices. Comparison with the anatomical patterns in a group of normal subjects. Setting: Private phlebology practice. Patients: Sixty-seven patients with primary varices (100 limbs) and 66 subjects without varices and with competent saphenous veins (120 limbs). Methods: Duplex ultrasound evaluation of the saphenous system in the thigh of patients and healthy subjects. The ‘eye’ ultrasonographic sign was used as the marker to distinguish the LSV from the longitudinal tributary veins of the thigh. Results: In 57% of limbs in patients with varices, reflux followed the saphenous vein, while in 43% the reflux spilled outside the LSV into an ASV (h or S types). When reflux followed the saphenous vein, no large calibre ASVs could be observed. In 30% of limbs in control subjects a parallel tributary vein with a similar calibre was found joining the LSV. Conclusion: Clinically visible varices in the thigh rarely comprise the LSV itself, but are usually dilated ASVs, the reflux stream passing from the proximal LSV into a more superficial ASV. The distal LSV running parallel beneath is often competent. In subjects with healthy LSVs, a large competent tributary vein is already present in the thigh in 30% of cases. This suggests that superficial deviation of reflux flow into an ASV in patients with varices may not arise from haemodynamically acquired changes, but could have a congenital origin. This could even be a predisposing factor in the development of varices.

Purpose: The relation between vein wall fibrosis and presence of primary venous reflux was investigated. Methods: Twenty-eight limbs of 27 patients undergoing coronary bypass surgery without history of superficial or deep venous thrombosis and without clinical evidence of varicose veins were subjected preoperative ultrasonic investigation of the long saphenous vein (LSV) and its tributaries in order to detect presence of reflux. Histologic examination of vein specimens, harvested perioperatively from premarked sites of the LSV (ankle, knee, and midthigh) and its tributaries, was carried out. The specimens were classified according to the fibrotic content of the wall on histology as normal, mildly, moderately, and severely affected. Results: Sixteen limbs (57%) had reflux. Saphenofemoral junction (SFJ) incompetence alone was not seen, and this always was present in association with an incompetent LSV (3/16, 19%). Reflux was equally distributed (37.5%) in the above(6/16) and belowknee (6/16) segments, whereas in three limbs it was present throughout the LSV. Fibrosis was seen in the majority of the specimens taken from the LSV (62/65, 95%) and its tributaries (21/32, 66%), irrespective of the presence or absence of reflux. Different grades of fibrosis were found on histology in different sites of the same vein. Conclusions: Venous wall fibrosis very often exists in the absence of reflux and venous insufficiency occurs at any segment of the LSV with minor involvement of the SFJ. Thus, primary venous reflux seems to be a locally developing process.

The possibility of ischaemic limb salvage by arterializing the superficial venous system was examined in a canine study. The experiment was carried out on four healthy dogs in three stages. In the first stage, collateral circulation to the hind limb was abolished. In the second stage, all branches of the common femoral artery were ligated, which created a model of ischaemia incompatible with limb survival. Revascularization was achieved by anastomosing the valvulotomized long saphenous vein to the common femoral artery, proximal to its ligation. The dogs were monitored for 2 weeks. All limbs maintained tissue oxygenation similar to that of the control contralateral limb. In the third stage, the artery was ligated proximal to the femoro-saphenous anastomosis and the limb monitored for 7 hours. Acute loss of motor function of the limb resulted. In the present study, arterialization of the valvulotomized long saphenous vein prevented limb loss in critical ischaemia.

Objective: The aim of this study was to determine whether an increased body mass index should influence the choice of continuous-wave Doppler probe frequency in the clinical assessment of patients with varicose veins. Design: Prospective assessment of the effect of raised body mass index on the accuracy of clinical assessment of venous reflux using 4 and 8 MHz Doppler probes compared with duplex scanning. Setting: The ultrasound department of a university teaching hospital. Patients: Seventy-two patients with symptomatic primary varicose veins (108 limbs), who had not undergone previous injection sclerotherapy or surgical treatment. Main outcome measures: Measurement of body mass index and assessment of reflux with hand-held Doppler using 4 and 8 MHz probes immediately followed by duplex scanning. Results: There was no significant difference between the 4 and 8 MHz Doppler probes in the accuracy of detection of reflux at the sapheno-femoral junction, in the long saphenous vein or at the sapheno-popliteal junction in the whole patient group or in the obese subgroup. Conclusion: Body mass index should not influence the choice of probe frequency (between 4 and 8 MHz) in the clinical assessment of patients with primary previously untreated varicose veins.

The long saphenous vein may be harvested from the thigh or the lower leg, depending on the operating surgeon's preference. This prospective study compared the incidence of altered wound healing between these two sites in 175 patients undergoing routine coronary artery bypass grafting over a 3-month period. The patients were divided into 3 groups. In group A, the vein harvest site was restricted to above the upper border of the patella. Group B included harvest sites that started at the ankle but extended above the level of the upper border of the patella. In group C, the vein harvest site was restricted to below the upper border of the patella. The wounds were assessed daily using the ASEPSIS scoring system. In group A, significantly more patients (24%) had an ASEPSIS score > 10, compared to group B (3%) and group C (2%). The mean ASEPSIS score was significantly lower in group C than groups A or B, 1.5 ± 2.4 vs. 6.5 ± 3.2 or 3.7 ± 1.7, respectively. The ASEPSIS score is reduced when vein harvest is restricted to below the level of the knee.

Objective: To report on the surgical treatment of varicose veins by angioscopic valvuloplasty to preserve the long saphenous vein (LSV) and the efficacy of this method compared with conventional stripping and high ligation. Methods: A total of 306 limbs in 187 patients with reflux at the sapheno-femoral junction to below knee level were operated on using intraoperative angioscopy to diagnose valve insufficiency. Angioscopic external valvuloplasty was attempted for the subterminal valves in the LSV by three techniques: total plication of the dilated annulus by running polypropylene sutures (technique 1), plication by autogenous femorofascial sleeve or Dacron-reinforced silicone (technique 2), and plication of the commissure with shortening of the cusps from outside the vein wall (technique 3). Partial stripping or segmental ligation was performed for varicose veins below knee level and the incompetent perforating veins were treated simultaneously by suprafascial ligation. Results: The subterminal valves were classified as follows: valves with elongated and atrophic cusps – type I, 136 (44%); valves with expanded and depressed commissures with cusp changes – type II, 108 (35%); valves that had cusps with other deformities – type III, 38 (13%); and absence of valves between the saphenofemoral junction and mid-thigh level, 24 limbs (8%). Valvuloplasty of the LSV was successfully performed in 62 limbs (20%). There were two cases with occlusion of the LSV (3%) and four with recurrence of varicose veins (6%) at 2–89 (mean 55, SD 21) months follow-up. Conclusions: Angioscopic external valvuloplasty is effective in the treatment of varicose veins to preserve the LSV. Further data are needed for complete evaluation of this procedure.

The aim of this study was first to select preoperatively suitable long saphenous vein (LSV) segments by using color flow duplex imaging (CFDI) and second to evaluate the quality of the harvested LSVs histologically. Forty LSVs in 38 consecutive patients (mean age 63 years) were examined by CFDI for patency and luminal diameter. None of the patients had documented previous deep venous thrombosis or superficial thrombophlebitis. Perioperatively, 79 LSV specimens were harvested from the ankle, knee, and midthigh regions and examined histologically for wall calcification and fibrosis. According to the amount of fibrosis present the specimens were classified as being normal or mildly, moderately, or severely affected. All LSVs were found patent and nonvaricose, and their diameter ranged from 0.18 to 0.54 cm at the ankle, 0.29 to 0.69 cm at the knee, and 0.25 to 0.77 cm at the midthigh level. On histology 11% of the specimens were found to be normal, and 43% were mildly, 38% moderately, and 8% severely fibrotic. Also, various grades of fibrosis were found in different sites of the same vein. None of the specimens had calcification. It is concluded that the majority of the LSVs used for coronary artery bypass grafting have some degree of fibrosis. The histologic appearance of the LSV wall in a particular site cannot predict the condition of vein throughout its length. CFDI can be useful in the perioperative conduit selection.

Objective: To define the relationship between the long saphenous vein and the connective framework of the subcutaneous tissue (hypodermis) of the lower limb. Methods: The connective skeleton of the hypodermis was studied by anatomical dissection, stereomicroscopy of cross-sectioned specimens and ultrasound imaging in 88 lower extremities. Results: The long saphenous vein runs for most of its length in a narrow compartment delineated deeply by the muscular fascia and superficially by a connective tissue lamina descending from the inguinal ligament in the anteromedial part of the thigh and medial aspect of the calf. These two fascia fuse at the boundaries of the compartment. The long saphenous vein adventitia is anchored to both fasciase by thick connective tissue strands. Conclusion: The anatomical relationship between the long saphenous vein and the connective framework of the hypodermis suggests that: (1) only the vein running within the deep compartment of the hypodermis should be considered as the ‘true’ long saphenous vein; (2) the other subcutaneous veins running outside the compartment should be considered as collaterals of the long saphenous vein; (3) the connective sheath surrounding the long saphenous vein could oppose dilatation of this vessel should valvular incompetence develop; and (4) thigh muscle contraction could modify the calibre of the long saphenous vein as happens in the deep veins. Finally, the authors propose to term the deep compartment of the medial thigh and the leg hypodermis the ‘long saphenous vein compartment’ and consequently the hypodermic connective lamina, by which it is superficially delimited, as the ‘long saphenous vein fascia’.

Objective:To assess a novel device designed for ‘inversion’ stripping of the long saphenous vein during varicose vein surgery.Design:A prospective, randomized trial.Setting:The Day Surgery Unit of a District General Hospital.Patients:Thirty consecutive patients undergoing unilateral, varicose vein surgery, all fulfilling appropriate requirements for day surgery.Outcome:Peroperative assessment of blood loss and postoperative assessment of complications, bruising, pain and length of stripper exit wound.Results:‘Inversion’ stripping caused less peroperative blood loss ( p < 0.01). It reduced postoperative morbidity (for pain at 1 week, p = 0.02) and gave an improved cosmetic result (with a smaller stripper exit wound, p < 0.01).Conclusion:An easy-to-use, ‘inversion’ stripping device is described that can reduce the postoperative morbidity often associated with primary varicose vein surgery and can enhance cosmesis.

Objective: Duplex ultrasound evaluation of the clinically diagnosed varicose long saphenous vein (LSV). Design: Prospective, single patient group study. Setting: Department of Surgery, University of Ferrara, Italy (teaching hospital). Patients: 378 patients, 509 limbs with primary varicose veins; 94 patients, 103 limbs with a visible, superficial varicose vein trunk on the medial aspect of the thigh. Main outcome measure: Duplex ultrasound detection of a varicose saphenous vein and/or segmental saphenous dilatation and their relationship to saphenous reflux. Results: In 98% of cases the varicose trunk visible in the thigh was demonstrated to be a tributary of the saphenous vein; 34% of the observed saphenous veins exhibited segmental dilatations in the thigh. This finding was related in every case to saphenous vein reflux with high velocity and turbulence ( p < 0.0001). Conclusions: High-resolution ultrasonography demonstrated that when a dilated varicose longitudinal vein trunk is visible and palpable on the medial aspect of the thigh it is most likely to be a tributary rather than the LSV. In addition, a varicose saphenous vein along its entire length essentially does not exist. However, when a dilated saphenous segment occurs, it seems to be related to high diastolic flow velocity and turbulence.

In order to determine the value of air plethysmography (APG) in the detection of acute deep vein thrombosis (DVT), the authors studied prospectively 79 consecutive patients referred for suspected acute DVT. All patients were examined with venography and APG. Venography demonstrated acute DVT in 38 patients. In 8 patients the DVT was confined to the calf and in 30 this was in the popliteal and/or more proximal veins. Venography was negative in 41 patients. An outflow fraction value with superficial occlusion of the long saphenous vein at the knee of less than 28% in combination with a venous volume of less than 50 mL identified all patients with acute proximal DVT. There was one false-positive result. However, isolated calf vein thrombi were equally distrib uted, and half of them were not detected. Air plethysmography is a reliable, inexpensive, easy to perform, and accurate nonin vasive test for the diagnosis of proximal acute DVT. It may be a useful screening test when there is a big demand for noninvasive tests, and relatively little time is available on a duplex scanner.

Objective: To assess the wall perfusion in normal and varicose veins. Design: Observational study. Setting: Departments of vascular surgery of private and public hospitals. Patients: Twenty-seven patients undergoing vein surgery (43 long saphenous veins) and eight controls operated on for femoral-popliteal bypass. Methods: Laser Doppler flowmetry assessing long saphenous vein wall perfusion 3 cm below the saphenofemoral junction. Results: Significantly reduced wall perfusion was shown in varicose long saphenous veins compared with normal veins: 16.3 (SD 10.3) versus 45.4 (SD 14.9); pConclusion: Our data suggest a primary or secondary role for lower perfusion within the vein wall in varicose veins.

Objective: To use duplex ultrasound scanning to compare limbs with recurrent and primary varicose veins and to identify connections between deep veins and recurrences. Setting: A non-invasive vascular laboratory in Melbourne, Australia. Patients: A study of 779 limbs with recurrent varicose veins previously treated by ligation or stripping of the long saphenous vein and 1521 limbs with primary varicose veins. Main outcome measures: Connections between deep veins and recurrent varices, reflux in superficial and deep veins, and outward flow in perforators as demonstrated by duplex ultrasonography. Results: Recurrence was due to reflux in the long saphenous territory in 71.8%, short saphenous reflux alone in 14.7% or outward flow in calf perforators without saphenous reflux in 5.2%, while no source was detected in 8.3%. Limbs with recurrent veins in the long saphenous territory were compared with limbs with primary varicose veins; there was more frequent outward flow in thigh perforators (25.2% vs. 16.2%) but no difference for deep reflux (20.7% vs. 17.5%) or outward flow in calf perforators (56.8% vs. 53.1%). The source for recurrence in the long saphenous territory was from a single large connection in the groin in 46.3%, multiple smaller proximal connections in a further 46.3%, or thigh perforators in 7.4%. The destination was to an intact long saphenous vein in 33.7%, major tributaries in 28.7% or to other varices in 37.6%. Limbs known to have been treated by long saphenous ligation alone were compared with those known to be treated by long saphenous ligation and stripping; the source was more likely to be from a single large vein in the groin (60.3% vs. 39.9%) and the destination was more likely to be an intact long saphenous vein or major tributary (75.0% vs. 55.2%). Conclusions: Duplex ultrasound scanning detected the source of recurrent varicose veins in over 90% of patients and demonstrated whether there were single large or multiple smaller connections in the veins affected, and this helps to select the most appropriate treatment. Recurrence after stripping the long saphenous vein was more likely to be due to multiple small connections passing to scattered varices and this may allow more simple treatment by injection sclerotherapy rather than repeat surgery.

Objectives: To clarify reflux patterns in the sapheno-femoral junction in legs with varicose veins that display incompetence in the proximal long saphenous vein on duplex scan examination. Patients and method: One hundred consecutive extremities were selected for ultrasound studies. Venous reflux was examined in the common femoral vein and long saphenous vein at five selected levels in the vicinity of the sapheno-femoral junction. Results: Duplex ultrasound examination confirmed that in 44 extremities reflux was detectable both in the long saphenous vein and common femoral vein indicating ‘true’ sapheno-femoral incompetence. In 56 legs reflux was limited to the long saphenous vein, whilst the first saphenous valve remained competent. The ultrasound examination suggested that in these cases the reflux originated from the numerous tributaries of the proximal long saphenous vein. Conclusion: Our findings emphasize the transfascial escape (reflux from the deep veins) is not a necessary precondition of long saphenous vein incompetence and related varicose veins.

Objective: To quantify the incidence and extent of structural changes present in the long saphenous vein of patients with arterial disease. Design: Observational study of saphenous vein morphology. Setting: Departments of Surgery and Pathology, Leicester Royal Infirmary. Patients: Sixty vein biopsies from patients undergoing arterial surgery. Main outcome measures: Intimal and medial thickness and morphology. Results: Smooth muscle cell hyperplasia, elastosis and fibrosis contributed to intimal thickening (> 10 μm) in 87% of veins. This was frequently associated with medial longitudinal muscle hypertrophy. Intimal thickness had a skewed distribution with a median (range) of 33 (8–381) μm, The upper limit of the normal range was 200 μm. The median (range) medial thickness was 293 (131–468) μm. Conclusions: Intimal thickening is common in the long saphenous vein of patients undergoing arterial surgery but is extensive in only a small proportion. The upper limit of the normal range was 200 μm.

Objective: To measure the distribution of valves in the long saphenous vein. Design: Morphological study of the intervalvular distance of the long saphenous vein. Setting: Department of Morfología, Facultad de Ciencias de la Salud (Universidad de Las Palmas de Gran Canaria, Spain) and Academic Vascular Surgery Unit, St Mary's Hospital, London, UK. Material: Twenty lower extremities from adult cadavers with no evidence of lower limb venous disease. Methods: Anatomical dissection of the long saphenous vein, with accurate measurement of valve distribution. Results: There were on average 8.7 valves in the long saphenous vein, with 6.3 above the knee and 2.4 below the knee. Conclusion: Contrary to classical anatomical texts on this subject there are more valves in the long saphenous vein in the thigh than in the calf.

Objective: To establish the 10-year results of long saphenous vein stripping in the treatment of varicose veins. Design: Single patient group study of patients who received surgical treatment for varicose veins 10 years earlier. Setting: Department of Surgery, University Hospital of Tampere, Finland. Patients: All men and a randomly picked sample of women were invited to attend for a follow-up examination; 81% (52 men, 74 women) participated. Intervention: Long saphenous vein stripping in all Patients. Main outcome measures: The presence of visible varicose veins as graded in four categories by clinical examination. Results: Seventy per cent of the operated legs in women free of varicosities or showed only minor varicose veins compared with 51% in men; 28% of the patients required further treatment (mostly sclerotherapy) for varicose veins. Conclusions: Long saphenous vein stripping combined with additional procedures results in a relatively low rate of severe recurrent varicose veins in 10 years.

Objective: To describe the author's own technique for treating long saphenous vein incompetence. Method: The long saphenous vein is stripped using a disposable stripper with the patient under general anaesthesia. Saphenous varices are managed by hook phlebectomy. Conclusions: The author's technique is effective in the management of large saphenous varices associated with long saphenous incompetence. The result is cosmetically satisfactory. Any residual varices are dealt with by sclerotherapy.

Objective:To evaluate the outcome of re-operation in the groin for recurrent varicose veins.Design:Retropective follow-up studySetting:Department of Vascular Surgery, Gentofte University Hospital, Copenhagen, Denmark.Methods and materials:Thirty-two patients with 43 operated legs. Operations were performed between January 1996 and the end of April 1997 and solely as a groin dissection; no stripping was done. Follow-up consisted of a clinical examination and duplex scanning with an ATL HDI 5000 scanner.Results:Sixteen cured legs, 17 with reflux beginning at mid-thigh, mainly a Hunter's perforating vein, and 10 with remaining reflux at the sapheno-femoral junction.Conclusion:Recurrence rate in the groin is acceptable. Stripping of the long saphenous vein is mandatory to bring down the recurrence rate from mid-thigh perforating veins. This is now standard procedure in our department.

The aim of this study was to evaluate, in a prospective, five-year follow-up study, selective saphenous vein repair (SSVR) (combined use of plication of the incompetent saphenofemoral junction [SFJ] and selective ligature of incompe tent veins). The effects of SSVR were evaluated by ambulatory venous pressure measurements refilling time (RT) and color duplex to detect the number of incompetent venous sites. From a group of 400 consecutive patients studied for venous incompetence 54 subjects were randomized in an SSVR and a control group. Criteria of inclusion were SFJ incompetence with presence of valve cusps and incompetence of two to five venous sites in the territory of the long saphenous. After five years 22 patients in the SSVR group and 21 in the control group completed the study. SSVR increased RT (p < 0.02), and the number of incom petent sites was decreased after five years (p < 0.02). In the control group RT was shorter and the number of incompetent sites increased (p < 0.05) after five years. In conclusion SSVR appears to be an effective, physiological treatment with good long-term (five-year results) on incompetence and on the prevention of new incompetent sites.

Venous aneurysm (VA) is a rare vascular lesion. The authors have experi enced 2 cases of VA: a seventy-year-old woman who had a 4 x 4 cm VA at the elbow and a forty-five-year-old woman who had a 1.5 x 1 cm VA in the long saphenous vein. In the second case, intraaneurysmal observation was per formed by angioendoscopy during surgery. Histologic examination of the re sected lesion proved that the basic structure of the venous wall was preserved in both cases, although a marked reduction in each component of wall was ob served. The authors reviewed the reported cases of VA and classified them into type I VA (cystic ectasia) and type II VA (fusiform ectasia). Type I VA is predominant in extremities and internal organs, while type II VA predominates in the cervical region. Their analysis of the reported cases indicated that although VA and varicose veins are both venous ectasias, VA is distinguishable from varicose veins by the following features: no sex difference, occurrence even in children, occurrence anywhere in the body, occurrence as a single lesion, and lack of prolongation of the vein.

The saphenous vein is an essential element in arterial bypass surgery. It is known to develop intimal thickening following transplantation to the arterial circulation. No data are available on the relationship of normal saphenous vein intimal area and the age or the gender of the patient. One hundred sixty-two consecutive, donated, cadaveric, midtibial samples of the long saphenous vein were harvested. The donors ranged in age from twelve to eighty-two years; there were 121 males and 41 females. The areas of the intima and media and the intimal ratio (intimal area/[intimal + medial area]) were calculated by computer videomorphometry. There was no correlation between the three variables and age, but there was a significant correlation between the gender of the donor and the intimal area (r2=0.25, P=0.0012) and the intimal ratio (r2=0.34, p = 0.0001) showing that females have a greater intimal area than males. These findings suggest that gender should be considered as a variable in the choice of suitable control values in subsequent human studies on the development of intimal hyperplasia in venous bypass grafts.

Aims: To evaluate the procedure of stripping by invagination of the long saphenous vein in the management of varicose veins. Design: Prospective study of 1,300 patients treated by stripping of the long saphenous vein by the invagination technique. Setting: Three quarters of the patients were treated at a private clinic and one quarter in a university hospital in Brussels, Belgium. Patients underwent stripping of the long saphenous vein under local or regional anaesthesia. Main outcome measures: The occurrence of peroperative haemorrhage, postoperative haematoma in the track of the long saphenous vein, when assessed by clinical examination and dysthaesia in the distribution of the saphenous nerve assessed by neurological examination. Results: In a total of 1,300 patients operated on using the author's technique there were only 6 haematomas in the track of the long saphenous vein and no serious peroperative haemorrhage was encountered. In 4 patients disturbances in the sensation in the area supplied by the saphenous nerve were detected. Conclusion: Stripping the long saphenous vein by invagination provides a safe alternative to conventional methods which may cause excessive damage to structures around the vein.

Objective: To compare two non-invasive methods of qualitative assessment of the long saphenous vein in terms of venous compliance. Design: Thirty-five long saphenous veins were examined. Compliance measurements have been calculated using: Method A in which an AV Impulse machine (Novamedix, UK) is used to generate a pulse wave in the long saphenous vein and the measurement of transit times are performed. Method B involves duplex ultrasound and venous occlusion of the long saphenous vein. Occlusive pressure measurements are used in both methods. Results: The mean vein compliance ratio measured in 35 long saphenous veins with the different methods was 0.23 (0.18–0.28) and 0.26 (0.22–0.30) using method A and B respectively. (Mean and (95% confidence interval)). The results show that a good correlation r = 0.91 and this was confirmed using methods of agreement. Conclusion: Both techniques give comparable results, however, the method involving Duplex is easier to perform. The research and clinical implications of these techniques remain to be assessed.

Design: Case report. Setting: Vascular Surgery Department, Hull Royal Infirmary, UK. Patients: A 79-year-old man with a history of right leg ulcer and pulsatile veins. Investigations and interventions: Clinical examination revealed findings of tricuspid regurgitation. Investigations included duplex scans, CT scan, arteriography and both trans-thoracic and trans-oesophageal echocardio-graphy. These all proved inconclusive. High sapheno-femoral ligation and stripping of long saphenous vein ligation procedure resulted in healing of his ulcers within six months Conclusion: Pulsatile veins in the leg may be due to tricuspid regurgitation or AV malformation. Echocardiogram, duplex scan and angiograms can help to differentiate between the two diagnoses. In this case, the above investigations were misleading and clinical examination here played the key role.

Design: Case report. Setting: University Hospital in the Czech Republic. Patients: Patient undergoing surgery for primary varicose veins. Interventions: The patient underwent attempted long saphenous vein stripping by passing a flexible stripper from ankle to groin. The stripper fractured at its upper end and a fragment of stripper became lodged in the internal iliac vein in the pelvis. This was removed at laparotomy. The patient made an uncomplicated recovery. Conclusion: Major complications of varicose vein surgery are rare. This unusual problem was probably caused by material fatigue in the stripper, leading to fracture near the upper end of the stripper.

Plication of the long saphenous vein at the sapheno–femoral junction (SFJ) is an alternative to flush ligation and stripping. This technique abolishes reflux at the SFJ without altering the vein; this may then be used for arterial surgery or coronary artery grafting. Candidates for plication were selected on the basis of ambulatory venous pressure measurements and duplex scanning. These tests indicate and quantify the degree of superficial venous incompetence. Plication of the SFJ reduces the calibre of the vein to 60–70% for a length of 1.5 cm, allowing the value cusps to close when flow in the femoral vein is reversed. In this study 20 limbs were evaluated (in 20 patients) 6, 12 and 24 months after plication. Venous reflux was significantly reduced and there was an improvement in signs and symptoms. Thus, SFJ plication seems to be an effective physiological alternative to flush ligation in some subjects. However, long-term results (> 5 years) must be still evaluated.

The peroperative discovery of a venous cavernous haemangioma covering the sapheno–femoral junction, presents a serious problem to the unsuspecting surgeon, due to lack of preoperative preparation and an unawareness of the connections of the vascular tumour. Only an experienced vascular surgeon can handle the problem without performing further invasive investigations and, consequently, a second operation. The fact that we have not found a similar case in the medical literature, encouraged us to describe the operation performed and to point out the possible pre- and per-operative complications.

External valvuloplasty of the sapheno–femoral junction restores valve function by reducing vein wall dilatation. For this purpose an external prosthetic support has been used surrounding the dilated proximal long saphenous vein. Perforated PTFE or Dacron grafts were used in order to decrease the risk of infection and thrombosis.

From September 1997 to January 1998, minimally invasive harvesting of the long saphenous vein was carried out on 30 randomly selected patients undergoing coronary artery bypass grafting. Two to 4 small skin incisions were made for subcutaneous dissection of the vein. The mean ratio of skin incision length to conduit length was 0.29 ± 0.01. The mean time for conduit preparation was 55 ± 2.6 minutes. Mean hospital stay was 9.2 ± 0.2 days. Morbidity in these patients was significantly lower than that of a control group of 100 patients who underwent the conventional open technique. The method was simple and effective in providing good quality venous conduits at low cost with improved patient satisfaction.

In order to elucidate the cause and pathology of varicose veins in the lower limb, the terminal valves of the long saphenous vein in 36 patients with varicose veins and ten control cases have been examined by light and transmission electron microscopy. Valve failure in the varicose group was thought to start with a depression in the valvular commissure and to proceed to extension of this depression and expansion of the space between the two valves. It was further thought that, in this group, reversal and tortuosity of the valve cusps, hyperplasia of the collagen fibres and irregularity of the course of elastic fibre layers represented secondary changes. In almost all cases, intimal fibrous thickening was present in the vein wall, and this was histologically similar to so-called phlebosclerosis. It was further confirmed that the degree of intimal thickening was correlated to the disease period, with greater thickening noted at the region under greater pressure load. Phlebosclerosis seemed to be proportional to the size of stress and pressure load time.