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Acta Phlebologica 2000 December;1(2):79-85

language: English

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


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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.

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