compounded by two pairs of gastrocnemius veins (19) .... sis of deep vein thrombosis (DVT) (61,62). ... of venous thrombosis in the calf and iliac veins is more.
Annals of the Royal College of Surgeons of England (1990) vol. 72, 188-192
Venous disease: investigation and treatment, fact or fiction? H J Scott
FRCSEd
Research Fellow
FRCS
Senior Lecturer
Research Fellow
G M McMullin
P D Coleridge Smith
FRCSEd
J H Scurr
FRCS
Consultant Surgeon
Department of Surgical Studies, University College and Middlesex School of Medicine, The Middlesex Hospital, London Key words: Varicose veins; Venous insufficiency; Clinical competence
This review looks at some clinical and experimental methods and treatments used in venous disease, and attempts to dispel some myths which have been associated with it. Over the last century numerous techniques have been introduced to aid the understanding of the physiology of normal legs and the pathophysiology of those with venous disease. Tourniquet testing along with clinical examination remains the only method of venous assessment in most hospitals. Venous ulceration in the past has been associated with deep vein incompetence, but the newer, non-invasive techniques of Doppler ultrasound and duplex examination are now identifying patients with leg ulceration who have superficial venous insufficiency and therefore a surgically correctable condition. Perforating veins and their possible role in the aetiology of venous ulceration along with invasive and non-invasive methods for their detection is reviewed. Some of the conservative compression treatments and dressings available for the treatment of venous ulceration are discussed. It is concluded that adherence to sound surgical principles remains the mainstay of the successful management of patients with venous disease
Venous disorders are a common problem (1). Varicose veins are the most common problem seen in district general hospitals, and are frequently treated without any investigations, often by relatively junior and inexperienced staff. The recurrence of varicose veins following both sclerotherapy and surgical treatment is often seen. Venous disease lacks the urgency inherent in arterial disease. How many surgeons can really claim a genuine
Correspondence to: Mr J H Scurr FRCS, Department of Surgical Studies, UCMSM, The Middlesex Hospital, Mortimer Street, London WIN 8AA
interest in the management of these patients? Sir Benjamin Brodie (2) observed in 1846 "I think it very probable that many among you pass the bedside of such a patient without thinking it worthy of attention." In a recent survey of major London teaching hospitals only two had ulcer clinics attended by a consultant. Our understanding of the venous system has been severely hampered by the lack of investigative tools and over the centuries many myths have developed. These theories have included the belief that varices were full of black bile (3); that venous valves were to prevent blood flowing into the feet and arms (4); that varicose veins were attributable to a high melancholy temper in men (5); and that ulcers should be kept open to allow drainage of evil humours (6). The last century has seen the introduction of numerous techniques allowing a more scientific approach to venous disease, but even these have been subject to misinterpretation. Many myths remain prevalent and this review attempts to dispel some of them. Before we can truly advance the treatment of venous disorders, we need to understand the physiology and in particular the pathophysiology leading to these problems. Clinical examination, perhaps aided by a tourniquet test, is the sole method of investigation in most hospitals (7). These examinations do not give enough information to exclude arterial problems; to identify the exact site of perforating veins, or to distinguish adequately between superficial and deep venous insufficiency (8,9). In 1868 Gay (10) and Spender (11), working independently, noted that varicose veins occurred without venous ulcers, and that venous ulcers could occur without varicose veins; though in some cases the two conditions may coexist. It is now often assumed that venous ulcers in the absence of varicose veins are due to deep venous insufficiency (DVI) (12). In our own series (13) about two-thirds of the patients presenting with
Venous disease symptoms of chronic venous insufficiency, lipodermatosclerosis, ulceration and eczema, had superficial venous insufficiency alone. This finding is supported by other workers (14,15). Doppler ultrasound and in particular the newer modality of duplex (16) (which incorporates B mode ultrasound with Doppler) have demonstrated that incompetent valves with consequent retrograde flow of venous blood exists in many limbs where varicose veins are not clinically apparent (17). Duplex has also demonstrated that in some cases of clinically obvious long saphenous varicose veins there is a competent saphenofemoral junction with an incompetent nearby thigh perforator. The short saphenous system is even more variable (18). The saphenopopliteal junction may be located anywhere from the mid-calf to the mid-thigh. This problem is compounded by two pairs of gastrocnemius veins (19) into which the short saphenous vein often empties (rather than into the popliteal vein). Identification of the correct anatomy is impossible by clinical examination. The common recurrences following varicose vein surgery, particularly around the popliteal fossa (20) may well be attributable to incorrect identification of the vascular anatomy (21). Many surgeons rely on tourniquets to determine whether there is deep or superficial venous insufficiency. There is no standard method of application or indeed no standard tourniquet which can be applied. Some large superficial veins are not compressed by tourniquets, and conversely in some patients, the deep veins along with the superficial system are compressed. The results of a tourniquet test can at best be a guide, and cannot be relied upon. Despite this, surgical treatment is planned on these results. The role of perforating veins in the development of venous ulceration remains a subject of controversy. Their existence is undisputable and has been well documented. Cadaveric dissections (22,23) combined with in vivo studies (24), have led to the description of many eponymous perforating veins (25). The pathophysiology of these veins remains uncertain. The 'blow-out theory' attributes the skin changes of venous disease to the transmission of high pressure through incompetent perforating veins (26,27). There are those who believe that no venous ulcer exists without these veins (28,29). However, other workers have disputed this and in a number of cases ulceration has been shown to be solely due to long saphenous insufficiency (30,31). Incompetent perforating veins have also been described as irrelevant (32). Bjordal (33) demonstrated that the main cause of raised venous pressure in patients with venous insufficiency was due to reflux of blood within the major venous channels. He demonstrated that the incompetent perforating veins contribute little to this pressure. Nonetheless, incompetent perforating veins have continued to be considered important and numerous techniques (34), operations (35,23) incisions and approaches (28,36), and instruments (37) have been described to divide them. All these procedures have been associated with complications including haemorrhage, skin necrosis
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and infection. Many published series (38-41) report widely differing results with ulcer cure rates varying from 40% (42) to 90% (43). Poor results have been attributed to missing incompetent perforating veins at surgery and the exact location of these veins remains a problem. A variety of techniques have been described to identify their position. These include fluorescein injection (44), thermography (45), infra-red photography (46), Doppler ultrasound (47) and phlebography (48,49). The only investigation found to show significant improvement over clinical examination was phlebography
(50,51). At surgery, many more veins are seen than are ever identified preoperatively and there is still no accurate method for locating incompetent perforating veins. Colour duplex may alter this. Venography is still considered the 'gold standard' for venous assessment, though poor patient acceptibility and a significant morbidity (52) limit its use. It is time consuming and operator dependent. In radiological departments where venograms are an occasional procedure performed by staff in training, results can be unsatisfactory and films difficult to interpret. Tourniquets used for identification of perforators also pose problems of interpretation. An ineffective tourniquet will lead to filling of the superficial rather than the deep veins. Cinevenography (53,54) overcomes some of these problems, but is only used in a few specialised centres. Duplex scanning has shown that short segments of reflux exist within an otherwise normal venous system (55). Reflux within the common femoral vein can coexist with a competent popliteal vein. Venography is unable to identify these abnormal segments. The significance of regional reflux has yet to be fully elucidated. Ascending venography identifies post-phlebitic damage, but not primary valve failure, a condition now recognised as a cause of DVI (56). In this syndrome the deep veins and valves look normal on ascending venography (57) and changes are only seen on descending venography. Descending venography will show floppy valves and reversed flow (58). The interpretation of descending venograms is difficult, as some 'clinically normal' limbs show reflux to below the knees (59,60). Venography has also been used for the definitive diagnosis of deep vein thrombosis (DVT) (61,62). Lensing et al. (63) using duplex have shown 100% sensitivity and 99% specificity for the detection of vein thrombosis in the common femoral vein and the popliteal veins. Detection of venous thrombosis in the calf and iliac veins is more difficult. Continuous-wave Doppler using a simple 5 MHz hand-held pencil probe, can be used to detect deep vein patency, vessel occlusion and flow direction at the bedside (64). Occlusion of major vessels such as the iliac, femoral and popliteal veins (which have few collaterals) can be diagnosed with this method to an accuracy of 90%. The sensitivity is 95% and the specificity is 90% (65). Eklof stated that every surgeon treating varicose veins should have a continuous-wave Doppler in his
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pocket (66). However, problems exist with this investigation and its reliability has been challenged by many authors (67-69). The major drawback of this procedure is that the vessel being insonated cannot be identified, making interpretation of the Doppler recording in regions with a complex anatomical arrangement difficult. When used in conjunction with tourniquets the problems are compounded. Bandaging for varicose veins has been a mode of treatment since the time of Hippocrates (70). Bringing patients into hospital, elevating the leg and cleaning the ulcer results in rapid healing. Compression is thought to be important in healing ulcers in ambulant patients, but how much, for how long, and how this compression should be applied, is not known. There have been many successful studies demonstrating improved ulcer healing using a particular technique, a particular bandage or a particular dressing. Until it is known what pathophysiological changes we are attempting to modify, and we have a method of monitoring these changes, we are unlikely to be able to design more effective regimens. The first stockings and laced bandages were used by Richard Wiseman in 1676 to repress humours impacted in the leg (71). The application of effective graduated compression has been the single most important factor in the successful control of venous disorders. Elastic stockings have been shown to give effective graduated compression (72-74), and have been shown to be more effective than bandages (75-77). Their use has been advocated for varicose veins, oedema, venous ulceration and following surgery or sclerotherapy (78). They are more acceptable than bandages, both cosmetically and for reasons of comfort and ease of use. Unfortunately, there are a number of patients who are unable to cope with them. The Textile and Clothing Standards Committee (which included medical personnel) prepared the British Standard BS6612: 1985 in 1985 (79). This led to the revision of the Drug Tariff allowing National Health Service prescriptions of stockings on FP10s. Nevertheless there are still venous clinics operating where stockings are not provided. In an attempt to heal ulcers many creams, pastes and dressing materials have been described. More than 100 different products have been advanced, many claiming magical cures for venous ulceration. Whilst the possibility of modifying wound healing remains, with the use of growth factors, our current generation of products rely on modifying the wound environment. Reducing infection is clearly important, and the application of paste bandages producing an environment similar to the septic tank aims to hold bacterial contamination at levels in which wound healing can take place. Hydrocolloid dressings have been advocated in producing a moist environment. Other dressings claim active properties promoting wound healing. Whatever the advantages or disadvantages of these dressings, adequate debridement, regular cleansing and good compression must remain the hallmark of proper treatment. This paper questions our approach to patients with venous disorders. It remains essential to correctly
identify and treat those patients with a surgically treatable condition and to apply sound surgical principles to the management of patients with venous disorders.
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74 Jones NAG, Webb PJ, Rees RI, Kakkar VV. A physiological study of elastic compression stockings in venous disorders of the leg. BrJ Surg 1980;67:569-72. 75 Tennant WG, Park KGM, Ruckley CV. Testing compression bandages. Phkebology 1988;3:55-61. 76 Coleridge Smith PD, Scurr JH. Optimum methods of limb compression following varicose vein surgery. Phkebology 1987;2: 165-72. 77 Wright DDI, Munro C, McCollum CN. How good are elastic bandages? Phlebologie 1988;41:794-5. 78 Scurr JH, Coleridge Smith PD, Cutting P. Varicose veins: optimum compression following sclerotherapy. Ann R Coll Surg Engl 1985;67:109-11. 79 British Standards Institution. BS6612:1985. British Standard Specification for Graduated Compression Hosiry, 1985. Received 19 October 1989
Book review Complications of Plastic Surgery by A McG Morris, J H Stevenson, A C H Watson. 442 pp, illustrated. Bailliere Tindall, London 1989. £52.50. ISBN 0 7020 1360 9 Plastic surgery is a technical rather than a diagnostic specialty. Its fascination lies in the restoration of function and the correction of deformity using a wide variety of techniques which the surgeon tailors to each patient's needs and which require skill, judgement, and experience in their selection. There is a temptation among those not trained in the specialty to read about the techniques, seemingly of apparent simplicity, and to be beguiled into applying them without thought or knowledge of the complications that can ensue. The results of such ignorant meddling can be disastrous for the patient and a source of great difficulty to the plastic surgeon, who is then called in to solve an avoidable problem. This little volume should be required reading for all surgeons, as it highlights the difficulties and dangers in a concise way, aided by useful photographs and clear diagrams. As can happen with multi-author books, it is uneven and there is sometimes a lack of emphasis on which complications are of
special note as opposed to those which are not. To exclude any specific mention of the problem of the burned hand, a common enough condition, but to include Marjolin's ulcer which is rare, is a case in point. It is insufficiently emphasised that exposure of the cornea demands early, even emergency, grafting if the eyelid is to provide corneal cover and to even hint to the inexperienced surgeon that to perform multiple z-plasties, to supposedly improve the appearance of scarring, will help to perpetuate folly and encourage complications which the book seeks to warn against. Future editions will undoubtedly be modified and a chapter on the medico-legal aspects of patient counselling and care in a specialty which is increasingly assailed by potentially litigious and dissatisfied patients should be included. Finally, it is to be hoped that future editions will have the text squarely placed on the page and not askew as it is in the reviewer's copy. J P BENNETT Consultant Plastic Surgeon Queen Victoria Hospital East Grinstead
