Published Research

Thesis

Objective Assessment of Venous Disease and the Effect of Treatment
Master of Surgery, University of Southampton 1993

Effective long term eradication of varicose veins (VVs) by surgical treatment remains elusive. The central hypothesis of the work presented in this thesis is that the standard treatment (sapheno-femoral junction (SFJ) ligation and multiple avulsions) of primary VVs in the distribution of the long saphenous vein (LSV) is inadequate in preventing long term recurrence. The aims of this thesis are to investigate this claim, to elucidate the reasons for recurrent varicosities and suggest improvements in treatment.

Two tests of venous function, supplemented by clinical assessment, were used to evaluate the results of surgical treatment. Duplex ultrasound to assess valvular function and photoplethysmography (PPG), to measure the overall deficit in venous function. I have validated the use of both these techniques by evaluating the accuracy and reproducibility against the clinical spectrum of venous disease.

The usual surgical treatment of primary VVs in the distribution of the LSV is ligation of the SFJ and multiple avulsions of the varicosities. As part of one arm of a prospective randomised study, the results of this treatment were evaluated in 56 limbs. They were assessed pre-operatively, 3 and 21 months after surgery by duplex scanning, PPG and clinical examination.

Three months after treatment the objective methods of evaluation showed improvement but 21 months after surgery there was a significant deterioration: Duplex scanning revealed reflux in 83% of LSVs, 52% of limbs had a PPG 95% refilling time of less than 15 seconds and 50% of limbs had moderate to severe recurrent varicosities. I found that there were three causes for recurrent varicosities: communicating vessels at the site of the SFJ ligation, mid thigh perforating veins and progression of the disease process to include sites which had previously been normal (eg the sapheno-popliteal junction).

Investigation of the role of medial calf perforating veins. Using duplex scanning, a simple test was developed to map the haemodynamics of these vessels in normal limbs and those with venous disease. Flow dynamics were assessed before and three months after surgery in 63 limbs of 39 patients with superficial venous disease. Successful surgical treatment of VVs resulted in correction of abnormal flow patterns in medial calf perforators. In order to improve the results achieved by SFJ ligation and multiple avulsions, a further 49 limbs were randomised to additional LSV stripping from the groin to the upper calf. In total, 105 limbs of 69 patients were prospectively randomised to either SFJ ligation and multiple avulsions or to additional LSV stripping.

21 months after surgery in those limbs that had additional LSV stripping there was a lower incidence (49%) of reflux on duplex scanning in residual LSVs in the calf, and the PPG 95% refilling times were significantly greater. In this group significantly fewer (16%) limbs had clinical evidence of moderate to severe recurrent varicosities than those limbs that had undergone SFJ ligation alone (50%).

Using objective criteria, it was demonstrated that SFJ ligation and multiple avulsions is an unsatisfactory procedure for the treatment of primary varicose veins in the distribution of the LSV. I have investigated the reasons for the recurrence of varicosities and I have demonstrated the benefits of additional stripping of the LSV from the groin to the upper calf.