The relation of venous ulceration with ambulatory venous pressure measurements

Transcription

1 The relation of venous ulceration with ambulatory venous pressure measurements.n. Nicolaides MS, FRCS, M.K. Hussein, MD, FRCS, G. Szendro, MD, D. Christopoulos, MD, PhD, S. Vasdekis, MD, and H. Clarke, PhD, London, United IGngdom Two hundred thirty-six limbs of 220 unselected patients who were admitted with venous problems (83 with ulcers) were studied with continuous-wave Doppler ultrasonography, duplex scanning, and ambulatory venous pressure measurements. Patients with evidence of deep venous disease because of reflux or obstruction in the deep veins on Doppler and duplex ultrasonic examination or with an ambulatory venous pressure greater than 45 mm Hg despite the ankle cuff had venography. One hundred fifty-three limbs had superficial venous disease (reflux in the superficial veins with competent popliteal valves), and 83 limbs had deep venous disease (popliteal reflux on duplex examination or deep venous obstruction on venography). No ulceration occurred in limbs with ambulatory venous pressure < 30 mm Hg, and there was a 100% incidence with ambulatory venous pressure > 90 mm Hg. linear increase occurred from 14% in limbs with ambulatory venous pressure between 31 and 40 mm Hg to 100% in limbs with ambulatory venous pressure greater than 90 nun Hg (r = 0.79). In the groups studied, an increased incidence of ulceration was associated with an increase in ambulatory venous pressure irrespective of whether the venous problem was the result of superficial or deep venous disease. mbulatory venous pressure has both diagnostic and prognostic significance in patients with venous disease. (J Vs SURG 1993;17:414-9.) Ulcers of the lower leg associated with abnormalities of the superficial and deep veins are common. They interfere with activity when they are painful and are a major cause of time lost from work in the Western world. It has been suggested that venous hypertension is the main factor predisposing to venous ulceration.1 The purpose of this study was to determine the relationship between ambulatory venous pressure (VP) and the incidence of ulceration in patients with chronic venous insufficiency. MTERIL Two hundred twenty-two patients (251 fimbs) with chronic venous problems referred to the Irvine Laboratory have been studied with continuous-wave Doppler ultrasonography, 2 duplex scanning, 3,4 and From the Irvine Laboratory for Cardiovascular Investigation and Research, cademic Surgical Unit, St. Mary's Hospital Medical School. Reprint requests: Professor.N. Nicolaides, Vascular Surgery Section, cademic Surgical Unit, St. Mary's Hospital Medical School, 10th Floor, Queen Elizabeth The Queen Mother Wing, S. Wharf Rd., LONDON W2 1NY United Kingdom. Copyright 1993 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North merican Chapter /93/$ /1/ VP measurements, s On the basis of the Doppler and duplex ultrasonic examination the limbs could be classified as having superficial disease only (reflu~l the superficial veins in the presence of competent popliteal valves) or deep venous disease (popliteal reflux). Venography was performed in limbs in which the above tests indicated the presence of deep venous disease or the VP was greater than 45 mm Hg despite occlusion of the superficial veins at the ankle by a pneumatic tourniquet (see Methods). 6 Thus the latter could be classified as having deep venous reflux, obstruction, or both. METHODS Clinical examination. Clinical examination provided information about the presence of varicose veins and sequelae of chronic venous disease, that\~ edema, liposclerosis, and ulceration (active or healed). Continuous-wave Doppler ultrasonography. This was a screening procedure that determined the presence or absence of deep venous obstruction, reflux at the saphenofemoral and saphenopopliteal junction, and popliteal veins. bidirectional Doppler ultrasonic blood flow velocity detector (Parks 1010; Parks Medical Electronics Inc., loha, Ore.) was used

2 ]?OURNL OF VSCULR SURGERY Volume 17, Number 2 Nicolaides et al. 415 routinely with an 8 MHz probe. In obese patients the 4 MHz probe had to be used. The examination was performed with the probe aiming at an angle of 40 to 60 degrees to the skin, to obtain optimum signals. The detection of chronic venous occlusion was determined when the patient was examined lying on a couch with the trunk at 45 degrees and the knee slightly flexed with external rotation of the leg. signal phasic with respiration, which augmented with compression of the thigh and calf with or without occlusion of the long saphenous at the knee, indicated a patent deep venous system. bsence of a venous signal or a signal that was continuous, nonphasic with respiration, and nonaugmented with calf compression was suggestive of venous occlusion. 2 Detection and localization of venous reflux was determined with the patient examined in the standing position with the weight on the opposite leg so that the examined leg was relaxed. The probe was placed in the groin over the femoral vein. Normally no flow could be detected in this vein during motionless standing because of the transducer's threshold. The calf of the examined limb was manually compressed to produce ejection of venous blood towards the heart. proximal flow was then detected in the femoral vein. If the valves of the common femoral and long saphenous veins were competent, no signal of reversed flow could be detected on release of the compression. This criterion was diagnostic of ab- ~hce of venous reflux in the veins of the groin. On the other hand, the presence of retrograde flow was indicative of reflux. This was considered to be the long saphenous when it could be abolished with manual compression of this vein or the application of a narrow tourniquet distal to the Doppler probe. Reflux, which was not controlled with this maneuver, was considered to be in the femoral vein. The probe was then placed over the long saphenous vein at the level of the knee, and compression of the calf was repeated. Detection of reflux in the long saphenous trunk confirmed valvular incompetence of this vein. Control of reflux by occluding the long saphenous vein proximally at several levels, with external digital L _,repression or tourniquets, indicated the level that incompetence started, that is at the saphenofemoral junction or at a midthigh perforator. The patient was then asked to face away from the examiner and relax the examined leg by slightly flexing the knee with his weight mainly on the opposite leg. The Doppler probe was then placed in the popliteal fossa, and the signal of the popliteal artery was detected. By keeping the probe in this position, the calf of the patient was manually compressed, and proximal venous blood flow was detected. The position of the probe was adjusted so that the optimum venous signal was obtained. bsence of retrograde flow on release of calf compression was indicative of competent valves. These were in the short saphenous vein when retrograde flow could be abolished with a narrow tourniquet placed distal to the probe. They were considered to be in the popliteal vein when reflux could not be abolished with occlusion of the superficial veins. 2 The detection of reflux as a result of gravity rather than a Valsalva maneuver was the standard test established in our laboratory because it was found to correlate with descending venography. 2 Duplex scanning. The duplex scan (Ultramark 4; dvanced Technology Laboratories, Bothel, Wash.) enabled the operator to visualize a particular vein by B-mode real-time ultrasonography using a 7.5 MHz imaging probe and to position a sample volume (2 x 3 mm) in its lumen by a gated directional 5 MHz Doppler beam. The popliteal vein was examined with the patients standing facing away from the examiner and holding on to a frame. The examined leg was relaxed with the knee slightly flexed and the weight mainly on the opposite leg. The probe was placed behind the knee pressing tightly on the skin, and its position was adjusted so that the three following structures could be identified on a longitudinal ultrasonic section of the popliteal fossa: the popliteal artery lying deepest, the popliteal vein more superficial and parallel to it, and the short saphenous vein most superficial. The presence of reversed blood flow indicated venous reflux, and this could be both heard and seen as a negative reflection on the screen. 3,4 Duplex scanning was used to determine the anatomy of the saphenopopliteal junction before operation? This test was used because previous studies demonstrated the high incidence of skin changes in the presence of popliteal reflux. 4 This is not the case with isolated femoral vein reflux. mbulatory venous pressure. 21-gauge "butterfly" needle was inserted into a vein on the dorsum of the foot and was connected to a pressure transducer-amplified (type 8041; Simonson and Wheel, Medico Teknik /S, lbertslund, Denmark) and recorder (Datasyn, Recorder 314; W. Electronic.G., Basel, Switzerland ), which provided a continuous recording of the pressure. The resting pressure was initially recorded with the patient in the standing position holding on to a frame. The patient then performed a standard exercise of 10 tiptoe movements at the rate of one per second. t the end of the exercise the patient remained still until the pressure returned to the resting level. This was repeated after

3 JOURNL OF VSCULR SURGER~ 416 Nicolaides et al. February 1993 inflating a 2.5 cm wide pneumatic tourniquet at the ankle to 80 mm Hg to occlude the superficial veinsp Limbs with VP less than 45 mm Pig when the ankle tourniquet was inflated were considered unlikely to have deep venous abnormality. Limbs with VP greater than 45 mm Hg even when the ankle tourniquet was inflated, were selected for venography because of the possibility of deep venous occlusion or reflux. 5 mbulatory venous pressure measurements were performed in all patients, and the time taken for the pressure to return to the standing resting pressure levels was the pressure recovery time. For practical reasons we measured the 90% recovery time (RT90) instead of the flail recovery time because it is easier to define it and also because it showed higher reproducibility. 5 Venography. Venography was performed whenever continuous-wave Doppler ultrasonography, duplex scanning, or VP measurements indicated deep venous disease (83 limbs). scending deep to superficial venography was performed with the x-ray table tilted (60 degrees) to the horizontal and the patient in the semierect position with the weight on the nonexamined leg. 21-gauge needle was inserted in a vein on the dorsum of the foot, and a narrow 2.5 cm wide pneumatic tourniquet was placed around the ankle and inflated to 100 mm Hg to occlude the superficial veins. The diagnosis of obstruction was confirmed by venography. 6 RESULTS The 251 limbs of the 222 patients studied were classified as shown in Table I. In 15 limbs (group 4) there was no evidence of venous obstruction or reflux in any of the deep or superficial veins. Clinically they had small spider venules or small varicosities. Superficial venous reflux (saphenofemoral, saphenopopliteal incompetence, or both) in the presence of competent femoral and popliteal veins was present in 153 limbs. Deep venous disease was present in 83 limbs: 53 with reflux only, 22 with deep venous reflux and occlusion, and 8 with illac occlusion only (competent popliteal). Eighty-three of the 251 limbs studied had ulceration (Table I). The incidence of ulceration in relation to the VP (without tourniquet) is shown in Fig. 1. No ulceration occurred in limbs with VP less than 30 mm Hg. linear increase occurred from 14% in limbs with VP between 31 and 40 mm Hg to 100% in limbs with VP greater than 90 mm Hg (r = 0.79). The incidence of ulceration in relation to VP in limbs with superficial venous reflux and in limbs with deep venous disease is shown in the table. In the three groups studied, the incidence of ulceration was related to the increase in VP irrespective of whether the venous problem was the result of superficial or deep venous disease. Fig. 2 shows the relationship between RT90 and the incidence of ulceration. It demonstrates that there is not any ulceration with RT90 greater than 20 seconds. high incidence of ulceration is associated with a short recovery time, and when the RT90 is less than 2.5 seconds the incidence of ulceration is 79%. Further subdivision of RT90 less than 2.5 seconds ~x~'~s technically difficult. The relation between incidence of ulceration and RT90 was an exponential curve. Fig. 3 is a plotted graph of VP versus RT90 when limbs with superficial venous disease and deep, venous disease with or without ulceration are represented. The association of VP with RT90 and ulceration is clearly shown in this graph. DISCUSSION The association of leg ulcers and varicose veins was recognized by the ancient Greeks. In modern times the first to use the term varicose ulcer were Gay and Spender in ,8 In fact Gay suggested that these ulcers should be called venous ulcers because he and later Hammons 9 stressed that they were not necessarily associated with visible varicose veins, but rather with abnormalities of the deep and communicating veins. The hypothesis was confirmed by uae phlebographic studies of Bauer, 1 who found evidence of postthrombotic damage of the deep veins in many patients with ulceration. For many years, venous pressure measurements have been the main method by which peripheral calf pump function has been assessed. Von Recklinghausen in 1906 and Houlson in 1911 were the first to measure the pressure in the veins by inflating a plastic capsule over the long saphenous vein and recording the air pressure required to collapse the vein. Using the same technique Beecher in 1936 demonstrated a reduction of the standing pressure during exercise. The first measurement of venous pressure by direct cannulation of a vein in the f6~ was performed by Barber and Shatara in The standing pressure was found to correspond to the hydrostatic pressure from the level of the heart to the point of measurement. Reduction of this pressure has been observed during exercise by McPheeters and Rice 12 and Pollack and Wood. 13 This reduction was found by Lofgren 1 to be significantly smaller in limbs with venous disease. rnoldi ~4,1s demonstrated that pressure changes occurring in the deep system were

4 , ~URNL OF VSCULR SURGERY Volume 17, Number 2 Nicolaides et al n= INCIDENCE OF ULCERTION (%} < MBULTORY VENOUS PRESSURE (mmhg} Fig. 1. Incidence of ulceration in relation to VP. >90 Table I. Incidence of ulceration in the three groups of limbs studied Group (n = 15), no reflux or obstruction mbulatory venous pressure No. Ulceration No. Group B (n = 153), superficial venous disease only Group c (n = 83), deep venous disease Ulceration No. Ulceration < > (13%) 7 1 (14%) 8 (22%) 14 3 (21%) 11 (38%) 15 6 (40%) 8 (47%) (70%) 8 (67%) (69%) 2 (50%) 6 4"(67%) 5 5 (100%) almost identical to those in the superficial system because of rapid equilibration, indicating that for practical purposes the pressure changes measured in the superficial veins represent those occurring in the deep veins. The precise mechanism by which the disturbance of venous physiology leads to skin necrosis was best explained by the hypothesis that venous hypertension leads to venular dilation and causes increased Capillary permeability. s a result, fibrin is deposited around ti.. capillaries. The removal of fibrin then is not possible because of the vein wall's fibrinolytic activator deficiency. Finally this fibrin deposit acts as a diffusion barrier and the overlying dermis becomes hypoxic. ny minor trauma then causes an ulcer) 6 Our study shows that the elevated VP as a result of venous disease (obstruction, deep venous incompetence, superficial venous incompetence, or combinations of these) are associated with an increased incidence of ulceration. When VP is less than 30 mm Hg, the incidence of ulceration is zero. The incidence of ulceration was found to increase linearly to reach 100% when the VP was greater than 90 mm Hg. In contrast, a linear relationship does not exist between the RT90 and the incidence of ulceration (Fig. 2). refilling time of more than 20 seconds is normal and means that the VP should be less than 30 mm Hg. refilling time less than 20 seconds is indicative of an abnormal VP that could have any value between 30 and 120 mm Hg (Fig. 3). Consequently, RT90 cannot grade the severity of venous insufficiency; it can only detect its presence. Operations by Kistner, ~7 where valve repair for primary valve incompetence was done in patients with symptoms of advanced chronic venous insufficiency, revealed a decrease in the VP, healing of most of the ulcers, but no improvement in refilling time. Therefore VP is the better index correlating with venous ulceration. Thus measurements of VP are not only of diagnostic but are also of prognostic

5 418 Nicolaides et al. TOURNL OF VSCULR SURGEK[' February n=37 INCIDENCE OF ULCERTION (%) n= n=56 n=28 n=17 < olQ RT90 (seconds} Fig. 2. Incidence of ulceration in relation to RT90. n = 24 > , e 90 I O Z~ 8O o o " el o ixo VP 7 t o~ OoO ~ mmhg 6o oo oo o e~ o 5O 40 3O 4," ~ ooo && ~ o ~o oix~ o ix ~-~o ~. 1 R# ix O n ~. ixix,,.8 ix o ixix O & O & 2O 10 /1ix ix 0 ix & RT90 (seconds) Fig. 3. mbulatory Venous Pressure plotted against RT90. (6, Primary varicose veins with no ulceration; i, Primary varicose veins with ulceration; o, Deep venous disease with no ulceration; o, Deep venous disease with ulceration.) significance. The higher the venous pressure during exercise the higher the incidence of ulceration. These findings led to the assumption that healing of ulcers and relief from symptoms of post phlebitic limbs should be expected with therapeutic measures that lower the VP. These measures include elastic compression of the leg by the use of elastic stockings, venous reconstruction of occluded segments of the diseased veins, and reconstruction to prevent venous reflux by surgical means The contribution of reflux in the calf veins and incompetent calf perforating veins to the VP in

6 .journl OF VSCULR SURGERY Volume 17, Number 2 Nicolaides et al. 419 the presence of competent popliteal valves has not been addressed by our study because color flow imaging was not available at the time. However, this is an important issue and should be elucidated by future studies. It will indicate the potential of operations to render popliteal valves competent in the presence of such calf vein reflux. REFERENCES 1. Lofgren EP. The operative treatment of varicose veins. In: Rutherford RB, ed. Vascular surgery. Philadelphia: WB : Saunders, Nicolaides N, Fernandes FJ, Zimmerman H. Doppler ultrasotmd in the investigation of venous insufficiency. In: Nicolaides N, Yao JST, eds. Investigation of vascular disorders. New York: Churchill Livingstone, Sandager G, Williams LR, McCarthyW[[, Flinn WR, Yao JST. ssessment of venous valve function by duplex scan. Bruit 1986;10: Szendro G, Nicolaides N, Zukowski J, et al. Duplex scanning in the assessment of deep venous incompetency. J VsC SURG 1986;4: Nicolaides N, Shull K, Fernandes FJ, Miles C. mbulatory venous pressure: new informations. In: Nicolaides N, Yao JST, eds. Investigation of vascular disorders. New York: Churchill Livingstone, Lundstrom B, Osterman G. ssessment of deep venous insufficiency by ascending phlebography. cta Radiol Diagn 1983;24: Gay J. On varicose disease of the lower extremities. The Lettsonian lectures of London: Churchill, Spender JK. manual of the pathology and treatment of ulcers and cutaneous disorders of lower limbs. London: Churchill, Hammons J. The operative treatment of varicose veins and ulcers based upon a classification of these lesions. Surg Gynecol Obstet 1916;22: Bauer J. The aetiology of leg ulcers and their treatment by resection of the popliteal vein. J Int Chir 1948;8: Barber RF, Shatara FI. The varicose disease. NY State J Med 1925;31: McPheeters HO, Rice CO. Varicose veins-the circulation and direction of venous flow. Surg Gynecol Obstet 1929;49: Pollack, Wood EH. Venous pressure in the saphenous vein in ankle in men during exercise and changes in posture. J ppl Physiol 1949;1: moldi CC. Venous pressures in the leg of healthy human subjects at rest and during muscular exercise. cta Chir Scand 1965;130: rnoldi CC. Venous pressures: the function of the venous pump in chronic venous insufficiency. J Cardiovasc Surg (Torino) 1961;2: Browse NL, Burnand KG. The cause of venous ulceration. Lancet 1982;31: Kistner RL. Primary venous valve incompetency of the leg. m J Surg 1980;140: Submitted ug. 26, 1991; accepted Mar. 3, 1991.