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P A R T I V
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CHRONIC VENOUS INSUFFICIENCY
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51.
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THE PRIMARY CAUSE OF CHRONIC VENOUS
INSUFFICIENCY
Michel Perrin and Oscar Maleti
BACKGROUND
DEFINITION
Primary venous insu ciency (PVI) is chronic venous dysfunction whose cause is neither congenital or secondary
(postthrombotic). Restricting our attention to chronic
venous insu ciency, that is, CEAP classes C
in the VEIN-TERM consensus conference,
only patients that present edema or chronic skin or subcutaneous lesions including healed and active ulcers, and we
will limit our focus to the primary cause of these problems.
Nevertheless it must be mentioned that edema is confusing,
as transient edema does not have the same severity grade as
permanentedema.
H I S T O R Y
For a long time C 3 –C 6 classes were supposed to be secondary (postthrombotic), but now we know, thanks to ultrasound investigations, that primary etiology is common in
patients classi edC
–C 6 .
3
One of the major merits of the CEAP classi cation has
been to take in account the etiology, information that was
missing in previous classi cations.
In the updated CEAP, another credit has been added,
the use of the advanced CEAP. In the advanced CEAP all
the signs listed in the C classes must be reported.
ple, a patient presenting with varices, edema, pigmentation,
and active ulcer will be classi ed C
2,3,4a,6
we are dealing with in this chapter the descriptor etiology
will always be primary, the descriptor anatomy will inform
what venous system is abnormal:super cial, deep, perforator and their possible combinations; lastly the descriptor
physiopathology will provide information on the physiologic anomaly that was identi ed in the eighteen veins or
groups of veins listed in the descriptor anatomy. For example, using advanced CEAP, a patient presenting re ux in the
–C 6 a s d e ned
3
1
we will discuss
2
For exam-
. In the problem that
great saphenous vein above and below the knee, the small
saphenous vein, and the calf perforators, and an obstruction
of the common iliac vein will be classi ed A
s,p,d
, P
r2,3,4,18,o7.
If we return to the patient described above in terms of
clinical and etiologic descriptors and if we add the anatomical and physiopathological descriptors, he will be classi ed
E p , A
C
2,3,4,6,
been used in few epidemiological studies.
s,p,d
, P
r2,3,4,18,o7.
Until now, the advanced CEAP has
3
In this chapter,
its use allows precise identi cation of not only the etiology
but also the underlying anatomical and physiopathological
anomalies of venousulcer.
EPIDEMIOLOGIC STUDIES
Only recent epidemiologic studies will be analyzed. Some
studies report the prevalence of C
4–8
population.
is information is displayed in Table51.1,
–C 6 in the general adult
3
but in these studies no data were provided concerning relationships between etiology and clinicalclass.
C O H O R T S T U D I E S
Until now precise information on the etiology, anatomic or
physiopathologic abnormalities have been only available in
–C 6 patients.
C
5
Analyzing 182 legs presenting chronic venous ulcers
–C 6 ) examined by duplex color sonography (DCS),
(C
5
Magnusson identi ed a primary etiology in 127 (69.8%)
8
and secondary in 55 (30.2%).
Among the primary patients,
sixty-two (49%) had only super cial insu ciency, forty- ve
(35%) a combination of deep and super cial re ux, fourteen (11%) had deep re ux alone (half of them in this subgroup had previously undergone saphenous vein surgery),
and six (5%) had no identi able re ux.
Mac Daniel used DCS examination and air plethysmog-
raphy (APG) in examining ninety-nine ulcerated legs (C
).
6
431
Table51.1 PREVALENCE OF CVI PATIENTS
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FIRST AUTHOR REF NO.
San Diego Population study
Criqui (2)
Edinburgh Vein Study ∗
Evans (3)
Polish study
Jawien (4)
Bonn Study
Pannier (5)
∗ In the Edinburgh Vein Study ankle are was used to qualify CVI 1, but as this sign is not listed in the CEAP classi cation, prevalence numbers might be distorted.
Conversely edema is not listed in the Widmer classi cation.
STUDY
Cross-sectional study
University Employees active
(2,211)
?
Cross-sectional
Edinburgh Residents
(1,566)
16–84
Cross-sectional
population study
Polish adults rural (21%) and
(40,095)
?
Cross-sectional
Bonn and rural respondents
(3,072)
18–64
POPULATION
STUDIED NUMBER
A G E
or retired
population study
urban area seeking medical help
regardless of the cause
population study
CLASSIFICATION USED TO
IDENTIFY CLINICAL STATUS
CEAP Edema 5.8%
Widmer clinical classes
CVI 2=C4 in the CEAP
CVI 3=C5–6 in the CEAP
CEAP Edema 10%
CEAP Edema 10%
PREVALENCE
Trophic changes 6.2%
M=2.3%
F=1.3%
Trophic changes 5.1%
Trophic changes
2.5 %
Sixty-four percent of the patients had a primary etiology
9
and 36% secondary.
In another series of 111 C
had super cial incompetence alone.
–C 6 legs, y-seven (51%)
5
10
In the group with deep
incompetence six legs (5%) had isolated deep venous incompetence and forty-two legs (44%) had mixed super cial and
deep venous re ux. Knowing that only twenty legs were
listed as suspected (fourteen) or proven (6)deep vein thrombosis, it is obvious that etiology was primary in mostlegs.
Tassiopoulos reviewed thirteen studies reported
between 1980 and 1998 which used DCS to assess 1,249
11
limbs with chronic venous ulceration.
e incidence of
previous DVT was 32% (95%; con dence interval [CI]
27–36) in 405 limbs where this information was documented. Ninety-two percent of the 1,249 limbs assessed
demonstrated venous re ux with isolated super cial venous
re ux present in 45% and combined deep and super cial
re ux in 43% of thelimbs.
A large English survey gives the pattern of venous re ux
in 496 limbs (C
–C 6 ) 12 (see Table51.2).
5
Nevertheless there is another series in which results concerning the patterns of re ux are more instructive. One hundred and twenty seven C
–C 3 . e most obvious di erence between the two groups
C
0s
was the presence of an axial deep re ux in the C
(odds ratio [OR], 2.7; CI 1.56–4.57; see Figure51.1).
–C 6 legs were compared with 274
4
–C 6 group
4
13
In contrast, presence of axial re ux in super cial veins
did not increase prevalence of skin changes (OR 0.73;
CI 0.44–1.2). e authors concluded that continuous
axial deep venous re ux is a major contributor to increased
prevalence of skin changes or ulcer with chronic venous disease compared with segmental deep venous re ux above or
Table51.2 PATTERN OF VENOUS REFLUX IN 496 LIMBS
WITH CHRONIC VENOUS ULCERATION
PATTERNS OF
REFLUX
Isolated SVR 230 46.4
SVR+ IPVs 28 5.6
SVR+ sDVR 54 10.9
SVR+ sDVR+ IPVs 9 1.8
SVR+ f-l DVR 88 17.7
SVR+ f-l DVR + IPVs 21 4.2
Isolated f-l DVR 49 10
Isolated sDVR 7 1.4
Isolated IPVs 2 0.4
f-l DVR + IPVs 7 1.4
sDVR+ IPVs 1 0.2
Abbreviations :SVR=super cial venous re ux; IPVs=incompetent calf
perforating veins; sDVR= segmental deep venous re ux was de ned as deep
venous incompetence in the presence of at least one competent deep vein valve
above or below the re uxing segment knowing that three venous segments were
investigated, the femoral, the below-knee popliteal, and the gastrocnemius veins;
f-l DVR= full-length deep venous re ux.
(Adapted from Reference10 )
NUMBER OF
LIMBS
PERCENTAGE
432 • CHRONIC VENOUS INSUFFICIENCY
I N V E S T I G A T I O N S
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Figure51.1 Descending venography. Deep axial re ux grade 4 according
to Kistner.
below the knee. Information on etiology was reported on
the whole group:E
302 legs (75%), E s 99 legs (25%), but
p
not perclass.
In the very well documented series of ninety-eight
limbs graded C
, sixty-six extremities (67%) were primary. 3
6
Super cial re ux with or without involvement of other
systems was seen in eighty-four extremities (86%), incompetent perforators were identi ed in seventy-nine limbs
(81%), and seventy-two legs (73%) had deep re ux with or
without involvement of other systems.
In the deep re ux subgroup, twenty-two extremities
out of seventy-two had a re ux grade 3 and 4 according to
14
Kistner classi cation
(grade 3=7; grade 4 = 15). Since
the VEIN-TERM consensus conference, grades 3 and 4 are
2
termed “axial re ux.”
It is worth noting that all patients
with a re ux grade 4 had a combination of super cial and/
or perforator insu ciency (ten super cial+ perforator, four
isolated super cial, one isolated perforator). Nevertheless
six legs had no axial super cial re ux.
From all these studies it is clearly established at present
that in patients classi ed C
–C 6 primary etiology is at least
4
as frequent as secondary etiology. is statement leads to
practical management.
M A N A G E M E N T O F C 4 C 6
PATIENTS
For some authors, 5 only patients who have chronic and permanent changes in the skin and subcutaneous tissues of the
lower leg are referred to clinically as having chronic venous
insu ciency (CVI), but in the updated CEAP, C3 patients
2
have been included inCVI.
As CVI is an expression of severity in chronic venous
disease, management guidelines for CVI patients need to be
stated both in terms of investigations and treatment.
Besides clinical examination, all C
–C
patients must be
3
6
investigated on level II as de ned in the revision of the
2
CEAP, which means mandatory DCS.
In most cases, that
allows documentation using the advanced CEAP classi cation. In other words, the physical signs, absence or presence
of symptoms, etiology, and anatomic and physiopathologic
abnormalities are usually clearly identi ed. It is essential
to know in every anatomical system, super cial, deep, and
perforator, what veins are obstructed or re uxing and what
etiology is identi ed:primary, secondary, or congenital.
In patients with CVI we recommend complementing the
CEAP classi cation by using the updated venous severity scor-
15
ing system,
as we know that in patients with C 3 –C 6 the two
other scoring systems, venous segmental disease score (VSDS)
and the venous disability score (VDS), might be useful,
16
although not validated.
When there is a discrepancy between
symptoms, C class and DCS ndings complementary investigations are needed, such as venography, venous helical CT
scan, magnetic resonance imaging, intravascular ultrasound
(IVUS) , and so forth, according to the venous diseasetype.
To quantify the global CVI severity investigations such
as ambulatory venous pressure and air plethysmography are
useful.
T R E A T M E N T
Methods of Treatment
e various treatment methods will be not described in this
chapter, as they are detailed in other chapters of the book.
Grossly they can be divided in two groups:conservative and
invasive or mini-invasive. e rst includes compression,
drugs, and physiotherapy; the second includes open surgery
and endovenous procedures in the three venous systems,
knowing that ablation (chemical or thermal) is only used in
super cial and perforatorveins.
e main di erence between conservative and nonconservative treatments is very important to keep in mind.
Conservative treatment is usually prescribed regardless of
the etiology, anatomy, and physiopathology of theCVI.
On the contrary operative treatments are selective, taking into account etiology, anatomic lesions, and physiopathologic disorders. Super cial venous re ux can be treated by
open surgery and endovascular ablation, and the di erent
techniques can be combined.
For treating perforator insu ciency all techniques
can be used: sclerotherapy, thermal ablation, ligation by
open surgery, and subfascial endoscopic perforator surgery
(SEPS).
Deep venous surgery is supposed to treat obstruction or
re ux. In primary etiology, obstruction was supposed to be
infrequent compared to re ux, but according to Raju and
Neglen, primary iliac vein obstruction prevalence is underestimated and underdiagnosed.
17
THE PRIMARY CAUSE OF CHRONIC VENOUS INSUFFICIENCY • 433
A
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B
Figure51.2 Venography using femoral access:(A)Le common iliac vein compression and re ux in le internal iliac vein. (B)Same patient a er
stenting. Re ux is no longer identi ed.
For treating primary deep iliocaval obstruction, balloon-
E cacy of compression according to the clinicalclass:
ing and stenting is the method of choice (see Figure51.2
AB), whereas valvuloplasty is the most used procedure for
C
treating primary deep vein re ux (Figure51.3).
17,18
. Compression reduces edema, but in all the studies
3
both etiology and physiopathologic disorders
Treatment Results
As the information concerning the outcome of the various
treatments is provided elsewhere in this volume, we will
focus on patients C
Surprisingly few studies give precise information both
on the clinical class and etiology in CVI except for classes
–C 6 Only controlled randomized trials (RCTs) with few
C
5
exceptions will be analyzedhere.
Elastic Compression
First of all it must be underlined that long-term compliance
with compression is di cult to estimate (between 30 to 60%),
but is not in uenced by the severity of the venous disease.
–C 6 withPVI.
3
19
(A) (B)
Internal Valvuloplasty
are not stated. ere is no RCT comparing
compression to operative treatment.
(eczema, pigmentation). ere is no RCT
C
4a
comparing compression to operative treatment.
(lipodermatosclerosis, atrophie blanche).
C
4b
One RCT has shown that stockings improve
lipodermatosclerosis, but C
detailed in this study.
–C 6 (healed ulcer, active ulcer). Many RCTs
C
5
20
etiology is not
4b
comparing di erent bandages are available, but
the results according to the etiology are not
documented.
Figure51.3 Internal valvuloplasty. e oppy incompetent deep valve is repaired. At the end of the procedure the free borders of the valve are in contact.
B
434 • CHRONIC VENOUS INSUFFICIENCY
In two trials compression is compared to surgery. In the
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21
rst trial, seventy- ve venous leg ulcers (VLUs)
— y-one
of primary etiology (forty-seven isolated super cial venous
insu ciency and fourteen with a combination of super cial and deep vein re ux), thirteen postthrombotic, and one
congenital—were randomized between minimally invasive surgical hemodynamic correction of re ux (CHIVA
is the French acronym for this method) and compression.
Healing was shorter in the CHIVA group (P < 0.02). At
a mean follow-up of 3years, recurrence rate was lower in
the CHIVA group (P < 0.05) and investigation parameters
such as quality of life (QoL) were improved in the CHIVA
group. But primary and secondary etiology were not evaluated separately, the extent of the re ux was not documented,
and the number of patients wassmall.
In the ESCHAR study, 500 consecutive patients with
VLUs presenting super cial venous re ux and mixed super cial and deep re ux were randomized in two groups receiving
either compression alone or in combination with super cial
22,23
venous surgery.
Deep venous re ux was assessed in three
locations: common femoral or femoral veins, above-knee
popliteal vein, and below-knee popliteal vein. When one or
two of the three studied deep segments were re uxing, deep
re ux was denominated segmental deep; when the three segments were involved, it was classi ed as totaldeep.
Primary end points were 24-week healing rates and 4-year
recurrence rates. Results were analyzed on an intention-to
treat basis. Overall healing rates were similar in both groups.
e rate of ulcer recurrence at 4years was 56% for the
compression group and 31% for the compression plus surgery group (P <0.01).
At 4years for patients with isolated super cial venous
re ux, VLU recurrence rates were 51% for the compression group and 27% for the compression plus surgery group
(P < 0.01)—At 3years for patients who had super cial +
segmental deep re ux, VLU recurrence rates were 52% for
the compression group and 24% for the compression plus
surgery group (P=0.04)—At 3years for patients who had
super cial + axial deep re ux, VLU recurrence rates were
46% for the compression group and 32% for the compression plus surgery group (P=0.33).
24
ese results are in accordance with Adam’s article.
In
a series of thirty-nine patients with VLUs in which super cial and segmental deep re ux were combined, segmental
deep re ux resolved in nineteen of thirty-nine (49%) and
ulcer healing occurred in thirty of thirty-nine (77%) limbs
at 12months a er isolated super cial venous surgery.
Chemical Ablation in Presence of Super cialRe ux
ere is no RCT comparing chemical ablation with
other treatment in PVI restricted to C
–C 6 patients, but
3
several articles report good outcomes in venous ulcer
a er foam sclerotherapy, however, etiology and presence or absence of combined deep re ux are not always
25,26
speci ed.
Two prospective studies are available, the rst one included
twenty-eight C6 limbs treated by ultrasound-guided foam
sclerotherapy as an adjunct for compression. Of chronic
VLUs, 96% healed within 3months, and only two healed
VLUs (7%) had recurred at 12months.
27
Another study with long-term follow-up is available.
patients were followed during a 45- to 68-month period
C
6
a er HL and ultrasound-guided foam sclerotherapy. At
4-year follow-up, the ulcer recurrence rate was around
30% in the present study, a value comparable with that in
23
the ESCHAR study
(estimated recurrence rate 31%) in
which patients were treated by conventional surgery plus
28
compression.
Open Surgery in Presence of Super cialRe ux
In the three RCTs comparing surgery + compression
with compression alone in C
venous surgery was performed.
–C 6 patients only super cial
5
21–23
In the rst one 21 it was
the CHIVA technique, that is high ligation + disconnection of the tributaries from the saphenous trunk. In the
22,23
second,
the procedures were isolated saphenofemoral
junction or saphenopopliteal disconnection, or combination of high ligation, tributary stab avulsion, and saphenous
trunk stripping (only for the great saphenousvein).
ere are no RCTs for C
–C 4 patients comparing sur-
3
gery with other treatment.
ermal Ablation in Presence of Super cialRe ux
ere are many observational studies and RCTs comparing open surgery with thermal ablation, but the outcome
is not reported according to the C class excepted intwo.
In one, 560 C
patients presenting saphenous and
6
perforator re ux were treated by endovenous laser ablation (EVLA) or classical surgery. e authors concluded
that EVLA healed most leg ulcers with primary CVI and
reduced the recurrence of ulcers within the rst 3years a er
29
treatment, but the treatment protocol is not clear.
In another observational study, in 88 limbs with recalcitrant VLUs, treated in a dedicated wound center by
compression over 5 weeks and showing no improvement,
incompetent super cial and perforator veins were treated
by endovenous ablation. Following successful ablation, the
healing rate for healed ulcers improved signi cantly (P >
0.05). A er a minimum observation period of 6months
76.3% of patients healed in 142 +/ 14 days. Twelve
30
patients with twenty-six ulcers did not heal.
Perforator Surgery
Although SEPS has been largely used for treating
–C 6 patients whatever the etiology, there are no RCTs
C
5
comparing results of super cial surgery with super cial surgery+ SEPS. In the North American Subfascial Endoscopic
31
Surgery Perforator study
(146 patients) SEPS was combined with super cial venous surgery in 103 patients (71%).
Patients with primary valvular incompetence had 1-year
THE PRIMARY CAUSE OF CHRONIC VENOUS INSUFFICIENCY • 435
(limbs at risk 41)and 2-year (limbs at risk 25)recurrence
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rates of 15% and 20%, respectively, compared with 47%
a er 2years in those of secondary etiology.
Deep Venous Surgery forRe ux
There are no RCTs comparing conservative treatment with surgery for correcting deep venous reflux.
Outcomes of this surgery remain difficult to judge, as
in PVI superficial, perforator, and deep reflux are frequently combined.
Nevertheless in many series treated by deep venous
reconstructive surgery, conservative treatment, or/and
super cial surgery, perforator ligation had been used previously and was unsuccessful.
e results of valvuloplasty, which is the procedure of
choice for correcting primary deep re ux, are summarized
in Table51.3.
In our series the ulcer recurrence-free survival was
75% at 5years (44 limbs) for PVI (C
Table51.3 VALVULOPLASTY RESULTS
–C 6 ) and among the
5
twenty-four limbs with PVI (C
deep venous reconstructive surgery.
) no ulcer occurred a er
4
32
Grossly deep valvuloplasty with or without previous or
concomitant super cial venous surgery and perforator ligation is credited at 5years with 70% good clinical (no ulcer
recurrence) and hemodynamic results:competence of the
18
valve(s) repaired.
It is worth noting that in all series treated by valve repair,
the deep re ux was an axial re ux.
Endovenous Treatment for Obstruction
Again there is no RCT comparing conservative treatment to ballooning and stenting, but most of the patients
treated operatively were previously not improved or stabilized by conservative treatment. In a series of 334 limbs
combining primary re ux and iliac vein compression (nonthrombotic iliac vein lesion:NIVL) 183 were C
, and 39 C 6 . 17 All were treated by dilatation and stenting.
C
5
, 69 C 4 , 6
3
Outcome was appreciated separately in limbs with isolated
AUTHOR
YEAR
Masuda 1994 (37) I 32 27/32 48–252
Raju 1996 (38) I 68 (71) / 12–144 16/68 (26) 30/71 (42) /
Raju 1996 (38) TMEV 47 (111) / 12–70 14/47 (30) 72/111 /
Sottiurai 1996 (39) I 143 / 9–168 (81) 9/42 (21) 107/143 (75) /
Perrin 2000 (32) I 85 (94) 65/85 12–96 (58) 10/35 (29) 72/94(77)
Raju 2000 (40) TCEV 141(179) 98/141 1–42 (37) (59)
Tr i p a t h i
2004 (41)
Rosales 2006 (42) TMEV 17 (40) 17/17 3–122 (60) 3/7 (43) (52)
Wang 2006 (43) TMEV (40) 40/40 (36) / (91)
Lehtola 2008 (44) I
ABBREVIATIONS
I=Internal Valvuloplasty
PVI=Primary Venous Insu ciency
TMEV=Transmural External Valvuloplasty
TCEV=Transcommissural External Valvuloplasty
AVP=Ambulatory Venous Pressure
VRT=Venous Re llTime
av=average
Ê=Improved
* No re ux or less than1s
SURGICAL
TECHNIQUE
I
TMEV
TMEV
I+TMEV
NUMBER OF LIMBS
NUMBER OF VALVES
REPAIRED
90 (144)
12 (19)
12
7
1
ETIOLOGY
P V I / T O T A L
118 (24) (32)
5/12
3/7
0/1
FOLLOWUP
MONTHS
MEAN
(127)
24–78
(54) / (55) /
ULCER
RECURRENCE
OR NON
HEALED
ULCER %
(28) 24/31 (77)*
(50)
HEMODYNAMIC RESULTS
COMPETENT AVP
VALVE %VRT
Ê 81% (av)
Ê 50% (av)
Normalized
63 % (av)
Ê 15% (av)
Normalized
100 %
(79.8)
(31.5)
Ê 50% (av)
Ê 50% (av)
/ /
436 • CHRONIC VENOUS INSUFFICIENCY
compression and compression and re ux, knowing that
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re ux was not treated. e cumulative results observed at
2.5 years a er stent placement in the NIVL subsets with
re ux and without re ux respectively were complete relief of
swelling for 47% and 53%, complete stasis ulcer healing for
67% and76%.
INDICATIONS
According to the reported results recommendations accord-
33
ing to Guyatt’s grading can be given.
ISOLATED SUPERFICIAL
INSUFFICIENCY
In presence of isolated super cial insu ciency operative
treatment is strongly recommended (Grade 1 B). As there
are now no RCTs comparing long-term outcome of the
various operative treatments (open surgery or chemical or
thermal ablation) the choice of the procedure to be used is
not clear. In the presence of major re ux at a very dilated
saphenofemoral or saphenopopliteal junction, particularly
when the terminal valve is incompetent, high ligation (HL)
remains legitimate combined with trunk saphenous stripping and stab avulsion of the incompetent tributaries.
Endovenous ablation does not include HL, and postoperatively a nonre uxing patent saphenous stump is usually identi ed at the saphenofemoral junction. What the
long-term results should be in the patients who had an
incompetent terminal valve with a massive re ux preoperatively, we don’t know. When terminal valve is competent
endovenous ablation must be considered.
In presence of axial deep re ux, phlebologists and
some vascular surgeons model their attitude to the one
adopted when a segmental re ux is identi ed. Compression
is prescribed a er control of super cial and perforator
incompetence.
But for others, including our teams, in patients graded
C5–C6 deep venous reconstructive surgery must be considered a er failure of operative super cial re ux treatment in
absence of contraindication, namely ine ective calf pump
(recommendation grade1A).
Valvuloplasty (single, multilevel, multisystem) is the
most suitable technique, internal is preferred by most surgeons, knowing this procedure has provided better outcome
18
than external valvuloplasty
ISOLATED PRIMARY DEEP
VEINREFLUX
(see Figure51.3).
is presentation is not common, but C 5 –C 6 or C 4b class
ndings in young patients who are reluctant to wear compression for all their lifetime and with extended deep re ux
18
are candidates for valve reconstruction
(recommendation
grade1A).
PRIMARY ILIOCAVAL AND FEMORAL
OBSTRUCTION COMBINED WITH
SUPERFICIALREFLUX
ere is a consensus in patients presenting CVI to treat
rst obstruction by stenting, but a single-stage combination of percutaneous venous stenting and super cial
ablation in patients with severe chronic venous disease is
34
safe.
ASSOCIATION OF SUPERFICIAL AND CALF
PERFORATOR VEINS INSUFFICIENCY
ere is no consensus agreement in this situation. As
a rst step isolated super cial venous surgery looks reasonable (recommendation 1C). If persistent incompetent perforators are identi ed a er operative treatment
and when the patient is not improved, namely recurrent
ulcer or progressive lipodermatosclerosis, they should
be treated by surgery (SEPS) or endovenous procedure
(recommendation1B).
COMBINATION OF SUPERFICIAL
VENOUS INSUFFICIENCY WITH
OR WITHOUT PERFORATOR
INSUFFICIENCY AND DEEP
VENOUSREFLUX
Presence of a deep segmental deep venous reconstructive
surgery is seldom considered, and the patient management
is the same as stipulated in the paragraphsabove.
THE PRIMARY CAUSE OF CHRONIC VENOUS INSUFFICIENCY • 437
PRIMARY OBSTRUCTION COMBINED
WITH DEEPREFLUX
Indications for treating primary iliocaval compression
remain debated, primarily because obstruction identi cation and its severity are not easy to determine. According
35
to Neglen, only IVUS is reliable.
In symptomatic patients
with CVI, most authors recommend ballooning and stent-
36
ing (recommendation grade 1A).
But if the patient is not
improved, valvuloplasty must be considered in patients pre-
18
senting persistent axial re ux.
P O S T O P E R A T I V E C O M P R E S S I O N
is problem is not resolved. ere is no rule stating how
long a patient must wear elastic compression a er any kind
of surgery. One must rely on clinical features, other investigations, or both. When there is no more edema or skin or
subcutaneous change, or when DCS and photoplethysmography parameters become normal or subnormal, compression should be discarded.
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