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Mondor disease of the penis is an uncommon condition characterized by thrombosis in the superficial dorsal penile vein (SDPV).Sonographic findings of SDPV thrombosis have been well documented in the literature. However, to our knowledge, the color Doppler sonographic findings of SDPV thrombosis involving the superficial external pudendal vein (SEPV) have not been reported before. We report the color Doppler sonographic findings of a case with SDPV thrombosis extending into the SEPV to its confluence with the long saphenous vein and discuss the importance of interruption in this venous drainage route as an etiologic factor of the disease.

Study objective The long saphenous vein (LSV) is commonly used in small children to obtain venous access, and is usually cannulated at the ankle using the anatomical landmark technique. This is a ‘blind’ technique, which frequently requires multiple attempts, and may be associated with complications and failure. This study compared ultrasound guidance and landmark technique for localisation of the LSV in infants and small children. Methods 40 children aged 6 months to 2 years scheduled for elective surgery were included in this prospective clinical observational study. The anticipated puncture site of the LSV at the ankle was marked by either a consultant paediatric anaesthetist or a trainee anaesthetist using anatomical landmarks. A Sono-site Micromaxx 13–6 MHz SLA transducer was then used to determine the distance between the mark and the LSV. The diameter of the LSV was also measured. Results Mean LSV diameters were 2.60±0.68 mm and not significantly different between consultant and trainee groups (p=0.34). The mean distance of the anticipated puncture site from the middle of the vein was 3.14 mm (± 2.78 mm). The use of anatomical landmarks would have resulted in failure to cannulate the LSV in 58 of 79 (73%) attempts. Consultant anaesthetists were more likely to be successful (14 of 42 (33%) attempts, mean distance from LSV 2.6±2.6 mm) when compared with trainees (8 of 37 attempts (22%), mean distance from LSV 3.7±2.9 mm, p=0.034). Conclusion Ultrasound guidance is superior to the anatomical landmark technique for localisation of LSV and may reduce the number of cannulation attempts in infants and small children.

Purpose: The purpose of this study was to examine the relationship among pressures obtained simultaneously in the popliteal, long saphenous, and dorsal foot veins. Method: Eight limbs were studied. One limb had an isolated popliteal vein reflux, and two had moderate long saphenous vein incompetence. No perforator or short saphenous vein insufficiency was detected. Pressures and recovery times of the popliteal/tibial and long saphenous veins were obtained with cannulation at the ankle level and insertion of catheters with a pressure transducer tip. The dorsal foot vein pressure was measured with the insertion of a scalp needle (14-gauge) connected to an external transducer. During 10 toe stands, recordings were simultaneously made in the three veins at the level of the knee joint, in the middle third of the calf, and 5 to 7 cm above the ankle with all the transducers at the same level (ie, same reference point). Results: In one limb the popliteal/tibial pressure increased at all calf levels, whereas pressures decreased in both saphenous and dorsal foot veins. The pressures decreased in all three systems in the remaining seven limbs. There was no statistical difference between the pressure drop in the long saphenous vein and the deep vein. However, the decrease of the dorsal foot venous pressure was significantly more marked compared with the other two veins at all levels. The recovery time was significantly increased in the long saphenous vein compared with the deep vein; recovery time was further prolonged in the dorsal foot vein. Conclusion: The dorsal foot, long saphenous, and popliteal/posterior tibial veins clearly exhibit different pressure waveforms in response to calf exercise. The postexercise pressure, the percentage pressure drop, and the recovery times are widely different, which indicates that the three veins behave hydraulically as separate compartments in limbs without significant venous insufficiency. (J Vasc Surg 2000;32:894-901.)

Background: Neovascularization is an important cause of venous reflux recurrence after high ligation of the long saphenous vein. The pathogenesis of this phenomenon is so far obscure. It is possible that a hemodynamic factor – a pressure gradient between the femoral vein and the residual long saphenous vein – could be the trigger initiating the process of neovascularization. Patients and methods: Venous pressure measurements on eight patients with primary varicose veins were performed in the erect position in the insufficient long saphenous vein on the thigh. Mean pressures in the quiet standing position and ambulatory pressures were considered. By interrupting the saphenous reflux either distally or proximally to the point of measurement the pressure conditions either in the femoral or in the crural veins were simulated. Results: With the tourniquet placed distally to the point of measurement, the venous pressure in the upper interrupted segment of the long saphenous vein (equivalent to the pressure in the femoral vein) remained uninfluenced during ambulation. In contrast, by interrupting the reflux proximally to the point of measurement, a marked decrease of the ambulatory pressure in the lower part of the long saphenous vein (equivalent to the pressure in the crural veins) was noted. Conclusions: A pressure difference occurs between the veins of the thigh and the lower leg during the activation of the muscle venous pump. This fact may explain the tendency of recurrencies of varicose veins after high ligation of the long saphenous vein as well as the initiation of reflux.

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.

Suppurative thrombophlebitis is a well recognised and potentially fatal complication of intravenous cannulation in burns patients. We report a case of an Afro-Caribbean patient with noninsulin-dependent diabetes who developed signs of systemic sepsis two weeks after a 14% total body surface area flame burn. Despite an initial paucity of clinical signs at the cannulation site, exploratory venotomy revealed frank suppuration within the long saphenous vein from the ankle to the groin. This was treated successfully by total excision of the vein and its tributaries and delayed wound closure. Following this, a retrospective analysis of the measured clinical parameters and blood tests revealed no obvious, missed pointers to the impending sepsis other than a dramatic increase in the overall daily insulin requirement. This had doubled over a 48-h period, preceding the clinical diagnosis by three days. The relevant literature and guidelines for management are reviewed.

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.

In this study, we measured the diameter of the competent long saphenous vein proximally and distally to the anastomosis of an isolated incompetent tributary in 12 patients. Measurements were made both before and 30-45 days after surgical removal of the tributary. The preoperative diameter of the saphenous vein proximal to the anastomosis was greater than distally. The difference between proximal and distal to the tributary veins sections diminished from 1.59 mm to 0.39 mm (p = 0.0033) after surgical removal of the tributary alone. This phenomenon may be compared with other hemodynamic occurrences between the superficial and deep system. The incompetence of a tributary induces a proximal dilatation of the long saphenous vein. The isolated ablation of an insufficient tributary appears to be a useful measure to prevent degeneration of greater saphenous vein function as this procedure reduces the saphenous diameter.

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.

Although sound evidence is lacking, many surgeons claim that stripping of the long saphenous vein (LSV) is best performed by invagination. The aim of this prospective, randomized study was to test the hypothesis that invaginating stripping of the LSV is associated with less pain, smaller haematomas and less frequent injury to the saphenous nerve. Thirty patients with bilateral varicose veins and incompetent LSV, but normal short saphenous veins and deep venous systems, were treated by high ligation and stripping of the LSV and multiple stab avulsions. At one side the stripping was performed by invagination (group I), while a classic stripping was done on the other side (group C), so that one leg served as the control of the other. The results were analysed on an intention to treat basis. The median surface of the thigh haematoma between post-operative day seven and ten was 115 cm2 in group I and 135 cm2 in group C (NS). The median pain score was 0.25 and 1.75 respectively (NS). The incidence of saphenous nerve injury was 13% in group I and 17% in group C (NS). At one month 23% of patients stated that the leg with the invaginating stripping had been the more painful, while 33% of patients claimed that the side of the classic stripping had been more painful. The results show that the benefit of invaginating stripping is not as obvious as is generally suggested.

Despite the many studies on venous haemodynamics using duplex, only a few evaluated the normal values, variability and reproducibility. Therefore, the range and variability of venous diameter, compressibility, flow and reflux were measured. To obtain normal values, 42 healthy individuals (42 limbs, 714 vein segments) with no history of venous disease were scanned by duplex. To determine the reproducibility the intra-observer variability was measured in 11 healthy individuals (187 vein segments) and the inter-observer variability in 15 healthy individuals (255 vein segments) and 13 patients (169 vein segments) previously diagnosed with deep venous thrombosis. Of the 714 normal vein segments, 708 (99%) were traceable, including the crural veins. Of the traceable vein segments, 675 (95%) were compressible and in 696 (98%) flow was present. Of the 42 common femoral vein segments, in 25 (60%) the reflux duration exceeded 1.0 s, but in the other proximal vein segments the reflux duration was less than 1.0 s (95% confidence interval 3.0–10.0). With the exception of the distal long saphenous vein, in the distal vein segments the reflux duration was less than 0.5 s (95% confidence interval 3.5–8.2). The coefficient of variation of the diameter measurements ranged from 14 to 50% and that of the reflux measurements from 28 to 60%. The κ-coefficient of the inter-observer variability in the classification of compressibility measurements in the patients was 0.77 and that of the reflux measurements was 0.86. This study shows that almost all veins were compressible in healthy individuals, except the distal femoral veins. In healthy individuals the duration of reflux of the proximal veins was less than 1.0 s and in the distal veins it was less than 0.5 s. The inter-observer variability of the reflux and compressibility measurements in the patients was good.

Cryophlebectomy, a more recent technique in varicose veins surgery, was evaluated in comparision with conventional techniques. Group IA: Microphlebectomy, invaginative stripping of the long saphenous vein, tourniquet, n = 90; group IB: only microphlebektomie and tourniquet, n = 72. Group IIA: Cryostripping of the long saphenous vein in combination with cryosurgical distal avulsion of varicosities and microphlebectomy, n = 112; gr.IIB: only cryosurgical distal avulsion of varicosities and microphlebectomy. Data were compared regarding duration of operation and hospitalisation and cosmetic outcome. Hospital stay (gr. IA: 9,1 ± 5,1 d vs. gr. IIA: 6,1 ± 2,1 d, gr.IB: 5,5 ± 2,3 d vs. gr.IIB: 4,8 ± 2,5 d) and duration of operation (gr. IA: 113,6 ± 35 min vs. gr. IIA: 67 ± 21,3 min, gr.IB: 74,4 ± 35,3 min vs. gr.IIB: 53,3 ± 15,5 min) were found to be significantly shorter and cosmetic result and postoperative discomforts improved in the cryophlebectomy-group. We conclude that the use of this combination of methods reduces invasivity, rises the patient's well-being and helps in cost-reduction.

Slow or no reflow is a serious problem complicating catheter-based revascularization of degenerated saphenous vein bypass grafts. We examined the efficacy of rapidly delivered, high-velocity injections of intracoronary adenosine to reverse 11 slow-flow events complicating stenting of diseased bypass grafts. Ten of 11 events were rapidly improved to TIMI 3 flow by this technique within 3.8+/-1.6 min of the initial adenosine injection. In an ex vivo model, 3-ml syringes created higher peak pressures and velocities than 10- and 20-ml syringes. We conclude that rapid and repeated high-velocity intragraft administration of adenosine is a promising new approach to promptly reverse no-reflow events complicating PTCA and stenting of diseased saphenous vein grafts. Ex vivo studies demonstrate a potentially important mechanical advantage with the use of small syringes for injection. Further randomized studies will be required to better define the mechanism(s) and efficacy of this approach for treating no reflow, including its use in native vessels.

Objectives: Composite sequential arterial bypass is a useful option for treatment of peripheral vascular disease when autologous vein is limited. We have described a modified technique for composite sequential bypass using an extended polytetrafluoroethylene (ePTFE) synthetic graft and the long saphenous vein. These are linked via a common intermediate section anastomosed to the native vessel arteriotomy in a diamond configuration (diamond anastomosis). Methods: The diamond composite sequential bypass procedure was performed on six patients to treat critical limb ischemia (gangrene, ischemic ulceration, severe rest pain). The proximal bypass grafts consist of ePTFE, to

Purpose: To determine which patients require subfascial endoscopic perforator surgery (SEPS) in addition to saphenous surgery to correct pathologic outward flow within incompetent medial calf perforating veins (IPVs). Methods: Sixty-two limbs of 47 patients undergoing sapheno-femoral ligation, stripping of the long saphenous vein in the thigh, and multiple phlebectomies (n = 51), sapheno-popliteal ligation and multiple phlebectomies (n = 10), or both (n = 1) were examined with color flow duplex ultrasound scan immediately before and a median of 14 weeks (range, 6 to 26 weeks) after the operations. Indications for surgery were varicose veins (n = 47, Clinical, Etiologic, Anatomic, Pathophysiologic grades C2&3), skin changes (n = 5, C4), and ulceration (n = 10, C5). Results: Surgery resulted in a significant reduction in the total number of limbs in which IPVs were imaged (40/62 or 65% preoperatively vs 23/62 or 37% postoperatively, P

Purpose: The prevalence of reflux in the deep and superficial venous systems in the Edinburgh population and the relationship between patterns of reflux and the presence of venous disease on clinical examination were studied. Methods: A cross-sectional survey was done on men and women ranging in age from 18 to 64 years, randomly selected from 12 general practices. The presence of varicose veins and chronic venous insufficiency was noted on clinical examination, as was the duration of venous reflux by means of duplex scanning in 8 vein segments on each leg. Results were compared using cut-off points for reflux duration (RD) of 0.5 seconds or more (RD ≥ 0.5) and more than 1.0 second (RD > 1.0) to define reflux. Results: There were 1566 study participants, 867 women and 699 men. The prevalence of reflux was similar in the right and left legs. The proportion of participants with reflux was highest in the lower thigh long saphenous vein (LSV) segment (18.6% in the right leg and 17.5% in the left leg for RD ≥ 0.5), followed by the above knee popliteal segments (12.3% in the right leg and 11.0% in the left leg for RD ≥ 0.5), the below knee popliteal (11.3% in the right leg and 9.5% in the left leg for RD ≥ 0.5), upper LSV (10.0% in the right leg and 10.8% in the left leg for RD ≥ 0.5) segments, the common femoral vein segments (7.8% in the right leg and 8.0% in the left leg for RD ≥ 0.5), the lower superficial femoral vein (SFV) segments (6.6% in the right leg and 6.4% in the left leg for RD ≥ 0.5), and the upper SFV (5.2% in the right leg and 4.7% in the left leg for RD ≥ 0.5) and short saphenous vein (SSV) (4.6% in the right leg and 5.6% in the left leg for an RD ≥ 0.5) segments. In the superficial vein segments, there was little difference in the occurrence of reflux whether RD ≥ 0.5 or RD > 1.0 was used; but in the different deep vein segments, the prevalence of reflux was 2 to 4 times greater for RD ≥ 0.5 rather than RD > 1.0. Men had a higher prevalence of reflux in the deep vein segments than women, reaching statistical significance ( P ≤ .01) in 4 of 5 segments for RD ≥ 0.5. In general, the prevalence of reflux increased with age. Those with "venous disease" had a significantly higher prevalence of reflux in all vein segments than those with "no disease" ( P ≤ .001). Conclusion: The prevalence of venous reflux in the general population was related to the presence of "venous disease," although it was also present in those without clinically apparent disease. There was a higher prevalence of reflux in the deep veins in men than the deep veins in women. Follow-up study of the population will determine the extent to which reflux is a predictor of future disease and complications. (J Vasc Surg 1998;28:767-76.)

Objective: Although a number of pharmacologic agents have been shown to reduce intimal hyperplasia in animal models of restenosis, to date no systemic agent has conclusively been shown to be effective in humans. Recently, considerable attention has been directed towards endothelin (ET), a potent vasoconstrictor and a powerful mitogen for vascular smooth muscle cells, as a mediator of intimal hyperplasia. Endothelin-1 has been shown to be mitogenic for human saphenous vein smooth muscle cells, and expression also is elevated in human vein graft stenosis. The aim of this study was the investigation of whether ET receptor antagonists can attenuate neointima formation in a laboratory model of vein graft intimal hyperplasia and the determination of whether the effects are mediated by a specific ET receptor subtype. Methods: We used an organ culture of human saphenous vein, a well-validated model of vein graft intimal hyperplasia. Paired segments of human long saphenous vein were cultured with and without the following antagonists: bosentan, a nonselective ET receptor antagonist; BQ 123, a specific endothelin-A antagonist; or BQ 788, a specific endothelin-B (ET B ) antagonist. After 14 days in the culture, the segments were fixed and processed and the sections were immunostained to facilitate the measurements of neointimal thickness with a computerized image analysis system. Results: The nonselective antagonist bosentan and the ET B selective antagonist BQ 788 significantly reduced neointima formation by 70% ( P = .001) and 50% ( P = .03), respectively, but the ET A antagonist BQ 123 had no significant effect on the reduction of neointima formation ( P = 1.0). Conclusion: The results of this study imply an important role for ET as a mediator of human vein graft intimal hyperplasia and imply further that a specific ET B antagonist may have a therapeutic potential for the prevention of vein graft stenosis. (J Vasc Surg 1998;28:695-701.)

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.

Background This paper describes local anaesthetic saphenous disconnection in elderly patients for the treatment of venous ulceration in legs with either saphenous venous reflux alone or in combination with deep venous reflux. Methods Ambulatory venous pressure was measured in 16 legs with saphenous vein reflux alone and in nine legs with combined deep and saphenous venous reflux before, immediately after and 3 months after saphenofemoral or popliteal disconnection. Ulcer area was measured by computerized planimetry before surgery and at 1 and 3 months after operation. No compression bandages or hose were applied after surgery unless the ulcers had not begun to heal after 1 month. Results In legs with saphenous reflux alone all ulcers healed without compression bandages at a median of 81 (range 14–253) days and the pressure relief index (PRI) improved significantly both after surgery and at follow-up. None of the ulcers in the nine limbs with saphenous and deep venous reflux healed without compression bandaging and the PRI was unchanged immediately following surgery and at follow-up. Conclusion Saphenous vein disconnection improves venous function and heals venous ulcers without compression bandaging if the deep veins are normal. This procedure under local anaesthetic may be particularly suitable for elderly patients, but long saphenous vein stripping should be added in young patients.

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.

background. Advantages of tumescent local anesthesia (TLA) have been described for use in ambulatory phlebectomy removing large varicose side branches. objective. To evaluate the TLA method for high ligation and stripping of the long saphenous vein with or without administration of intravenous sedatives. methods. Forty-nine patients underwent 58 phlebosurgical procedures, including 41 ligations and strippings of the long saphenous vein. They were kept in the hospital for 24 hours after surgery to record potential complications and demand for medical assistance. results. The surgical procedures were easily performed under TLA without major complications. Minor complications were mild hematoma (n = 2) and temporary inguinal seroma (n = 1). Forty-one percent of the patients required additional IV sedation and analgesia perioperatively. Postsurgical guidance by a physician was necessary only in patients on full-dose heparin. conclusion. The tumescent technique for local anesthesia allows high ligation and stripping of the long saphenous vein even in both legs in one session, however, frequently with additional IV medication.

Mycotic aneurysms leading to aortoduodenal fistula (ADF) are associated with high morbidity and mortality. We report a patient with a mycotic aneurysm and ADF who required emergency laparotomy. After excision of the aneurysm, vascular reconstruction was performed using an autologous graft. The left long saphenous vein was harvested and constructed into a spiral graft. The graft was inserted using a standard inlay technique. After 12 months the patient is in good health. No inflammation or dilation of the saphenous vein spiral graft has been noted. We suggest that in the emergency treatment of mycotic abdominal aneurysm, aortic reconstruction with saphenous vein spiral graft is a valuable option.

We present a case of vascular compromise from an intracapsular hip fracture, which has not previously been documented. Management involved Austin–Moore hemiarthroplasty and arterial repair with long saphenous vein patch. We emphasise the importance of considering such complications due to potential limb loss from acute arterial insufficiency.

Right heart failure is associated with increased systemic venous pressure, which can be diagnosed clinically with the findings of elevated jugular venous pressure, pulsatile liver and distinctive cardiac murmurs (precordial systolic). Severe tricuspid regurgitation (TR) has occasionally been known to lead to marked pulsation of varicose veins. We report three cases that were referred to the vascular clinic of Royal Perth Hospital in which the patients involved had unilateral (right leg) varicose veins and chronic venous ulcers. On clinical examination all three patients had pulsations along the course of the varicose long saphenous vein up to the mid calf. The main differential diagnosis was arterio-venous malformation, which was excluded by compression of the sapheno-femoral junction and demonstrating absence of pulsation in the long saphenous vein. A venous duplex scan showed a grossly incompetent sapheno-femoral junction with abnormal wave forms. Two of the cases were managed conservatively with compression dressing. The option of sapheno-femoral junction ligation was reserved in one patient who had unsettling cellulitis and oedema of the lower limb in spite of compression dressing and optimal conservative management. All three patients had improvement in ulcer size at 3-month follow up with compression therapy. This article highlights that in cases of right heart failure the venous pressures can be felt as low as the mid calf level and that can be a cause of the venous ulcers. There should be a high suspicion of right heart failure in patients with late onset venous insufficiency.

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.

Purpose: The aim of this study was to assess the anatomic distribution and extent of deep venous reflux in patients with primary varicose veins (PVVs) and to investigate its influence on venous hemodynamics. Methods: Femoropopliteal venous reflux was examined using duplex color Doppler ultrasonography in 356 limbs with PVVs in 240 patients. Photoplethysmography (PPG) was performed using above-knee and below-knee tourniquets to determine the contributions of deep and superficial venous insufficiency. Results: Of 356 limbs with PVVs, 61 (17.1%) had femoropopliteal venous reflux, 42 (11.8%) had superficial femoral venous reflux alone, and 57 (16.0%) had popliteal venous reflux alone. Femoropopliteal venous reflux was associated significantly with clinical symptoms and shortened the half venous refilling time measured by PPG, especially in the presence of incompetent perforating veins. These findings were obtained regardless of the presence of long saphenous vein reflux. Conclusions: Femoropopliteal venous reflux associated with PVVs plays an important role in the pathophysiologic mechanism of venous stasis and influences venous hemodynamics in the presence of incompetent perforating veins and short saphenous vein. (J Vasc Surg 1997 26:260-4.)

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.

We studied the time course of micro-embolism by recording high intensity transient signals (HITS) on Doppler venous blood flow studies during a 7-day period in 57 of 63 consecutive patients after hip or knee replacement. No HITS were found before surgery, or in the non-operated leg after surgery. In the operated leg, the median number of HITS per minute showed an exponential decrease with time; a 50% reduction in the number of HITS took 72 minutes. Regardless of the duration and severity of HITS, we found no clinically apparent embolic event. Colour Doppler imaging at days 8 to 10 after operation showed a deep venous thrombosis in 17% of our patients with one thrombosis of the long saphenous vein. The presence or severity of HITS did not predict the venous thrombi. Although we found no pulmonary complications, we detected micro-emboli over a longer period after surgery than is usually reported. Spectral analysis of the Doppler venous signal is a repeatable and non-invasive monitoring technique in the post-surgical period. We failed to prove a correlation between deep venous thrombi and micro-emboli detected by this method.

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.

Little doubt exists regarding the supremacy of the left internal thoracic artery when anastomosed to the left anterior descending artery. The unique biology of the Left internal thoracic artery (LITA) and the extensive run-off into the LAD territory contributes to a patency of over 90% at 10 years.1 In comparison the long saphenous vein is prone to the adverse effects of thrombosis, intimal hyperplasia and harvesting trauma. Late patency is 80% when saphenous vein is used to bypass the left …

Ehlers-Danlos syndrome (EDS) leads to abnormalities in the synthesis of collagen and complications involving arterial vessels. We describe here a mutation in the intron 14 of the COL3A1 gene leading to EDS Type IV (EDS IV) associated with venous manifestations only. The patient, an 18-year-old male, suffered from truncal varicosity of the long saphenous vein on both sides. Conventional stripping surgery of the left saphenous vein revealed an extremely vulnerable ectatic superficial femoral vein. An inserted vein graft occluded, and venous thrombectomy was unsuccessful. A conservative anticoagulant and compression therapy finally succeeded. This is the first report describing EDS IV due to a mutation in intron 14 of the COL3A1 gene leading to venous manifestations without affecting arterial vessels at clinical presentation. Our findings imply that molecular genetic analysis should be considered in patients with unusual clinical presentation and that conservative therapy should be applied until a suspected clinical diagnosis has been secured.

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.

Eighty patients with primary varicose veins of the long saphenous system were randomized to have the long saphenous vein removed either by stripping to below the knee or by sequential avulsion. There was no difference between the two methods in the time taken to remove the vein. There was significantly more pain after stripping during the week following operation (P < 0.001). Median pain score after stripping was 5, reducing to 3 at 1 week, compared with 2, reducing to 1, for sequential avulsion. Median area of bruising measured at 1 week was 160 (range 0–1800) cm2 for stripping and 56 (range 0–544) cm2 for sequential avulsion (P < 0.01). Sequential avulsion is less painful, reduces bruising and avoids a significant scar below the knee.

background Since the literature indicated that in the early stages of primary venous disease valves are simply dilated, some authors performed external valvuloplasty of deep and superficial venous valves with encouraging results, although some failures were observed without being sufficiently explained. objective To obtain further interpretations of the natural history of venous valve pathology, clarify methods for a correct diagnostic approach, and provide indications for the external valvuloplasty procedure. methods Forty-two proximal valves of the long saphenous vein removed for varicose veins of the lower limbs were studied with optical microscopy. The relationship between histologic alterations and age of varicose disease was investigated. Five valvuloplastics were explanted for recurrent reflux and submitted to histopathological observation. Preoperative echographic findings and histologic observations were compared. Nineteen limbs were subjected to external valvuloplasty under angioscopic control; preoperative echographic findings and angioscopic observations were compared. results The histologic alterations observed in venous valves were mainly hypotrophy of cusps, which seemed to be the main cause of failure after external valvuloplasty. The frequency of such hypotrophic alterations increases with the age of varicose disease but no statistically significant relationship was found. Preoperative echographic imaging of venous valves does not appear sufficiently predictive when compared with histologic and angioscopic examinations. conclusion Hypotrophic valve damage seems to be prevalent in patients with varicose veins of the lower limbs. Valve cusp hypotrophy may be present in early disease though some normal cusps can be found in advanced disease. When preoperative echographic visualization of cusps is doubtful, intraoperative angioscopy plays the main role in the diagnosis of venous valve disease before and during external valvuloplasty.

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.

We report five cases of adipo-lymphatico venous transfer (ALVT) performed to treat unilateral obstructive lymphedema of the lower extremity. ALVT is a surgical procedure that utilizes the long saphenous vein and its surrounding lymphatic tissue from the unaffected limb for the treatment of lymphedema. Since ALVT does not necessitate anastomoses of lymphatic vessels, it can be performed regardless of the severity and duration of lymphedema, and stable longterm results can be obtained when the transferred lymphatic tissue shows viability. Department of Plastic and Reconstructive Surgery, Osaka Medical College, Osaka, Japan. Acknowledgments: We thank Dr. R. Harries and The Australian Cranio-Facial Unit for their assistance in the preparation of this article. Presented at the 12h Congress of the International Microsurgical Society, October 1994, Nara, Japan. Correspondence to Dr. Yoshio Tanaka, Department of Plastic and Reconstructive Surgery, Osaka Medical College, Daigakucho 2-7, Takatsuki City, Osaka, Japan 569.

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.

✓ To evaluate the late results and the natural history of long saphenous vein bypass grafts (SVGs) between the extracranial and intracranial circulation, the authors retrospectively analyzed 202 consecutive SVGs performed at the Mayo Clinic from 1979 to 1992. The distal anastomosis was to the vertebrobasilar system in 98 patients and to the carotid artery system in 103 patients. Surgical indications were advanced cerebroocclusive disease in 63% (127 cases), giant aneurysm in 37% (74 cases), and neoplasm in one patient. In 125 patent SVGs follow-up information was obtained for longer than 1 year and in 23 patent SVGs it was over 10 years (maximum 13 years, median 6.5 years). Most of the graft failures (76%) occurred during the 1st year after surgery, with 42% of all graft failures found during the first 24 hours after operation. Late graft attrition occurred in only 10 patients (8%). Cumulative patency at 1 year was 86% ± 3%, at 5 years 82% ± 4%, and at 13 years 73% ± 19%. Neurological worsening at the time of occlusion developed in 72% of patients with early occlusion, whereas 80% of patients with late graft occlusion had no new neurological symptoms. Long-term patency of SVGs for cerebral revascularization appears to be excellent, with an average failure rate of 1% to 1.5% per year following the 1st year after surgery. To minimize early graft thrombosis, meticulous attention must be paid to technical detail.

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.

Purpose: Work posture and occupation are among the most controversial predisposing factors associated with venous disease. We examined the distribution and extent of venous reflux in the lower extremities of symptom-free vascular surgeons, who were typically classified as leading a life of prolonged standing, in comparison to a group of symptom-free volunteers. Methods: In this prospective study (January 1991 to April 1994), the venous system in the lower limb veins of 28 vascular surgeons (56 limbs) and 25 normal volunteers (50 limbs) was examined by color-flow duplex imaging. The two groups were matched for age (29 to 45 years) and sex (all men). Subjects with clinical signs and symptoms of venous disease, history of deep or superficial vein thrombosis, or previous venous operation or injection sclerotherapy were not included in the study (12 vascular surgeons). Results: Venous reflux was detected in 29 limbs of vascular surgeons (52%) and in 16 limbs of the control group (32%) (chi-squared test=4.232, p = 0.039). In the latter, superficial venous incompetence was detected in 9 of 50 limbs (18%), deep venous or perforator incompetence in 3 of 50 limbs (6%), and venous incompetence involving both the superficial and deep systems in 4 of 50 limbs (8%). In the group of vascular surgeons, reflux in the superficial veins was seen in 22 of 56 limbs (39%), in the deep and or perforating veins in 4 of 56 limbs (7%), and in both the superficial and deep veins in 3 of 56 limbs (5%). Superficial venous reflux was more frequently encountered in the limbs of 45% of vascular surgeons (25 of 56) than in the limbs of the control subjects 26% (13 of 50) (chi-squared test=3.99, p = 0.047). Distal long saphenous vein reflux alone accounted for 39% (5 of 13) of any superficial venous incompetence in the limbs of the control subjects, and was higher, at 48% (12/25), in the vascular surgeons. Reflux in the gastrocnemial veins was equally distributed between the limbs of the control subjects (10%) and the vascular surgeons (11%). Conclusions: Venous reflux was more frequently seen among symptom-free vascular surgeons than normal individuals of a nonmedical vocation. The superficial system was by far the most common site of venous incompetence in both groups. Below-knee-long saphenous vein reflux in any combination was present in more than 75% of the limbs with superficial venous incompetence. (J VASC SURG 1995;22:150-4.)

The early outcome and morbidity associated with varicose vein surgery were assessed at six months post operation by postal questionnaire. Most cases underwent sapheno-femoral ligation, above-knee stripping of the long saphenous vein and multiple stab avulsions. A 73.8% response rate resulted in 155 replies, and revealed a high incidence (65.8%) of perceived complications within the first two weeks after surgery. The commonest of these were bruising, pain and numbness. Over a third of patients consulted their general practitioner (GP) postoperatively. Half of these required further management or treatment and the rest, reassurance alone. At six months 79.4% were satisfied with the outcome of their surgery, although some still claimed problems with residual veins, skin discoloration, numbness, and ankle or foot discoloration. Eleven percent were referred to hospital for further opinion, mostly because of perceived residual varicose veins. The difference between residual and recurrent varicose veins is discussed. No patient felt that the standard 2.5 day admission was too long, and 12.9% thought it too short. Day case surgery is not a popular option in this population group.Despite high satisfaction rates, there is a considerable morbidity attached to varicose vein surgery. We believe that good pre- and perioperative communication, augmented by a comprehensive information sheet, is important to prepare patients for those postoperative problems and thus reduces their perceived importance.