IV. Investigations
IV. Investigations
Fernando Vega Rasgado, Mexico
Although the UIP has published two venous consensus guidelines on ultrasoundguided sclerotherapy (UGS), the authors of this paper suggest that a standardized report of venous ultrasound is required for uniformity in applying the method. This standardization should take into account details of the equipment used for UGS, pictures or drawings of varicose veins, ulcers or other findings, a systematic description of the venous system emphasizing permeability, reflux after Valsalva’s maneuver, as well as further details such as diameter, wall thickness, intensity of reflux, etc. Thus, a consensus report on venous UGS should provide a standard for the correct interpretation of the examination and results by all specialists.
Alfred Obermayer, Austria
The authors introduce a simple and helpful method of Duplex investigation for atypical and severe venous leg ulcers, which they refer to as “Duplex Sourcing,” and which they describe both theoretically and by the use of images. The technique may be used to differentiate venous ulcers from mixed ulcers or from leg ulcerations with different etiologies (eg, Erithema nodosum), by detecting the origin of the local venous hypertension. A “swinging blood column” is described by Obermayer as a blood column that swings back to refill empty veins when manual compression of the ulcerated area is released. The author considers that exposing this sign using duplex is evidence for “venous ulcer” diagnosis even in the 19.7% of patients who have no visible varicose veins. Obermayer underlines that a crossover pattern or a small diameter may lead to wrong diagnosis, inaccurate treatment, and early recurrence. “Duplex Sourcing” can help detect the responsible superficial reflux routes, eg, postthrombotic syndrome and peripheral arterial disease in mixed ulcers.
Frederic Vin, France
In this study of 750 patients with an incompetent great saphenous vein (GSV), the authors performed a duplex scan examination of the groin to locate the different sources of reflux. The results of the study demonstrate that incompetence of the GSV is not always due to incompetence of the terminal valve (only 46.3% of cases in this study). The incompetence of the saphenofemoral junction was the source of the reflux in 62.4% of cases, and in 37.6% of cases the source of reflux was the pudendal veins, perforating veins, intersaphenous connections, or other sources of reflux. The lymph node network was involved in 1.2% of cases, but is more frequently involved in recurrent varicose veins after surgery. The authors concluded that duplex scan examination of the source of GSV reflux is necessary before any treatment in order to avoid early recurrence. The competence or incompetence of the saphenofemoral junction should be checked and other sources of reflux identified.
Erika Mendoza, Germany
Recent data by Mendoza confirm that the diameter of the great saphenous vein (GSV) is a relevant criterion correlated with clinical class and venous clinical severity scores (VCSS). This is found in all groups (good discrimination between presence or absence of reflux between healthy and diseased legs). The measurement of GSV diameter at the proximal thigh level is more sensitive and more specific than measurement at the saphenofemoral junction. The diameter of the GSV at proximal thigh level also has a better correlation with reflux. The study also demonstrated a moderate correlation in the group with refluxing GSVs, and an even stronger correlation between VCSS and the diameter of the GSV at the proximal thigh as compared with the groin.
Nicos Labropoulos,USA
The authors performed a PubMed search for the period 1991 to 2012 for papers discussing the impact of venous pathology in patients with leg ulcers. Twelve studies were selected for systematic review. Isolated deep venous reflux caused by either primary insufficiency or postthrombotic syndrome was infrequently reported (range 2.1%-19%). This does not, however, contradict the significant role played by deep reflux in ulcer development, as it is commonly found in conjunction with reflux in other systems. Combined insufficiency is associated with a greater risk of ulcer recurrence after surgical intervention. Concerning mixed disease, simultaneous involvement of the superficial and deep venous system was frequently reported, and triple system disease was cited as the most common cause of ulceration in most papers that examined all three systems. A previously documented episode of deep vein thrombosis was reported in a median of 33% of ulcerated limbs. The study has some limitations. Obstruction was rarely investigated in the studies analyzed in this paper and in the instances when obstruction was reported, the severity was not clarified. The patient population in the papers examined varied greatly and there was insufficient information provided about their status at the time of the study. As the papers examined spanned at least two decades, there may have been variability in the quality of information obtained from venous duplex in earlier studies due to the inevitable evolution of equipment!
Stefano Ermini, Italy
The role of perforating veins in venous disease is a topical issue. Doppler ultrasound scan is a useful tool for understanding the role of perforators, but such a technique requires dynamic exploration and training. The exploration must be performed with the patient in an active standing position, with maneuvers than can reproduce the perforator flow activity with muscle systole and diastole (contraction and relaxation outward flow).
