Target selection for surgical intervention in severe chronic venous insufficiency: Comparison of duplex scanning and phlebography

Abstract Purpose: The goal of this study was to determine whether duplex scanning (DS) alone, compared with ascending phlebography (AP) and descending phlebography (DP), would have been sufficient to guide treatment of severe chronic venous insufficiency (CVI), CEAP Clinical Classes 5 and 6. Methods: Beginning in 1994, patients presenting to the VA Sierra Nevada Vascular Clinic with ulceration due to CVI, CEAP Clinical Classes 5 and 6, were examined with DS, AP, and DP. Phlebography mainly guided surgical interventions. The ability of DS findings to select surgical interventions, with the aims of diversion of reflux from area of trophic skin or reduction of global venous hypertension was compared with phlebography. Of the 33 male patients (age, 29-70 years; average, 55 years) considered for operative interventions between January 1994 and November 1999, 30 were selected for operative treatment. Results: DS was 100% sensitive and specific for detection of complete occlusion of the superficial femoral vein (10/10) and for saphenous incompetence; sensitivity was 95% (19/20); and specificity was 100%. However, DS failed to reveal subtle changes in recanalized femoral veins because of prior thrombophlebitis, which was uncovered by AP in six of 23 patent femoral veins. There were 16 positive findings on AP of residual thrombophlebitis, of which six were not read on DS. Sensitivity was 63%, specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 53%. Reflux grading with DP agreed with DS in 23 of 33 cases or varied by one grade in five of 33 cases: sensitivity, 82%; specificity, 75%; positive predictive value, 96%; and negative predictive value, 37%. Kistner grade 4 reflux involving the superficial femoral and popliteal veins was noted by DP in five of the 33 cases when DS described reflux as "moderate." Incompetent superficial femoral vein valve stations in the upper third of the vein, which caused primary reflux, were clearly defined by DP in four of 33 cases; valve location was not well defined by DS. Below-knee perforator identification with DS was difficult; this was related to the severity of lipodermatosclerosis and the presence of ulceration. The number of perforators described at operation with subfascial endoscopic perforator surgery (n = 13) averaged 6 ± 2, whereas AP identified an average of 4 ± 2 in supramalleolar area. In four men, two previously undiagnosed caval and two iliac obstructions were detected with AP; one was corrected with Palma bypass grafting. Follow-up at 4 to 60 months (average, 40 months) showed four ulcer recurrences among 30 patients who were operated on. Two patients underwent repeat operations on the basis of repeated phlebographic study and are cured at this time, one patient was healed with conservative therapy, and one patient is lost to follow-up. Conclusions: DS would have been inadequate for identifying surgical targets in CVI, CEAP Clinical Classes 5 and 6. DS overlooked iliac and caval lesions. Potential valveplasty sites, which were only delineated on DP, resulted in four valveplasties in the upper third of the superficial femoral vein for grade 4 reflux. AP localized mid- to upper-leg perforators, but neither AP nor DP detected perforators in the range of 5 to 10 cm above the calcaneus. The net effect of phlebography was a choice for deep interventions in five (17%) of 30 cases, which would not have been possible with DS alone. The identification of iliocaval occlusion influenced the decision, based on prior experience, not to perform distal procedures in three cases. (J Vasc Surg 2000;32:913-20.)