The relative importance of incompetent communicating veins in the production of varicose veins and venous ulcers

Abstract

To investigate the possible anatomic and hemodynamic reasons for the variability in response to surgery for venous insufficiency (a 50% ulcer recurrence rate following ligation of incompetent perforating veins), we performed phlebography and venous pressure measurements in 109 legs of 77 patients and in 30 healthy volunteers. Patients were divided into five groups: saphenofemoral incompetence alone (group 1), saphenopopliteal incompetence (group 2), incompetent lower leg communicating veins alone (group 3), calf communicating veins and saphenous incompetence (group 4), and postthrombotic limbs (group 5). Patients in groups 1 through 4 had phlebographically normal deep veins. As compared to the normal controls (68%), preoperative pressure measurements revealed a significantly smaller pressure fall during exercise (deltaVPex) in all groups, which was the least marked in groups 3 (26%) and 5 (17%). These latter two groups failed to increase their pressure fall with thigh tourniquet. deltaVPex 3 months after operation demonstrated normalization in groups 1, 2, and 4 (52%, 57% and 59% respectively). Groups 3 and 5 improved little following surgical ligation. Whenever saphenous vein incompetence coexists with lower leg communicating vein incompetence, the former appears to be the dominant cause of the pressure abnormalities. Based on venous pressure measurements and phlebography, patients with normal deep veins and who increase their deltaVPex with a thigh tourniquet should respond favourably to orthodox surgical ligation of the saphenofemoral or saphenopopliteal junction. By contrast, if no change in deltaVPex is noted in patients with incompetent perforating veins and the deep veins look abnormal on the phlebogram, then ligation of the incompetent communicating veins would appear to be associated with a high recurrence rate.