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A Journal on Phlebology
Acta Phlebologica 2000 December;1(2):79-85
Perforating veins and chronic venous insufficiency. Hemodynamic indications and therapy
Camilli S., Guarnera G., Furgiuele S., Mascellari L., Platone A., Lorido A.
Department of Vascular Surgery and Pathology, Istituto Dermopatico dell’Immacolata (IRCCS) - Roma
Incompetent perforating veins (IPVs) play an important role in whole pathophysiology of the chronic venous insufficiency (CVI) of the lower limbs. Detection of IPVs by Duplex scanning seems to be easy and reliable. In the case of large IPVs, ligature is generally recommended. Nevertheless, some recent prospective studies concluded that Duplex is not mandatory in most cases and that IPV ligature was followed by no significant hemodynamic improvement nor ulcer healing. What to think and what to do? We suggest a different approach depending on different hemodynamic pattern in venous reflux. Considering the large experience in descending phlebography, we detected 5 different Types of venous reflux and a combination of these. The 1st Type is the known classical one in which the whole reflux depends on the sapheno-femoral (or popliteal) junction incompetence and absence of IPVs: the laboratory tests will be normalised by tourniquet application test. The 3rd Type (see 5 phlebograms) is characterised by primary deep venous insufficiency (PDVI) and large IPVs: the laboratory tests will not be normalised by tourniquet application test. IPVs are usually detected and their ligature is mandatory. The 5th Type (see 2 phlebograms) is that with absence of venous reflux at Scarpa triangle but coming from the abdominal level, via epigastric collaterals or gluteal or obturatorial or pudendal IPVs. The remaining 2nd and 4th Types (see 4 phlebograms) being intermediate patterns (see the text). IPVs are usually detected and their selective ligature is recommended. Considering the 5 different hemodynamic patterns of the venous reflux in CVI, and their combination, we suggest to apply different hemodynamic indication and more appropriate therapeutic strategy. Perspective studies are necessary to demonstrate if this strategy will evidence better results at a late follow-up.