Elsevier

Journal of Vascular Surgery

Volume 16, Issue 6, December 1992, Pages 913-920
Journal of Vascular Surgery

Original Articles from the Eastern Vascular Society
Comparison of descending phlebography with quantitative photoplethysmography, air plethysmography, and duplex quantitative valve closure time in assessing deep venous reflux,☆☆

Presented at the Sixth Annual Meeting of the Eastern Vascular Society, New York, N.Y., April 30–May 3, 1992.
https://doi.org/10.1016/0741-5214(92)90054-CGet rights and content

Abstract

To assess the role of noninvasive tests—quantitative photoplethysmography, air plethysmography, and quantitative duplex scanning, we compared a group of normal (group N, eight limbs) volunteers to patients with severe chronic venous insufficiency who were stratified according to the degree of reflux seen on the current “gold standard,” descending phlebography. Group M (10 limbs) had mild (grades 0 to 2) reflux, and group S (10 limbs) had severe (grades 3 to 4) reflux as determined by phlebography. Quantitative photoplethysmography could identify normal from abnormal limbs but could not distinguish the severity of reflux. Air plethysmography was used to calculate venous filling index, ejection fraction, and residual volume fraction. Ejection fraction was the same in all groups. Venous filling index could not significantly distinguish the degree of reflux (group M vs group S) but increased as reflux increased. Residual volume fraction was considerably higher in group S. Quantitative duplex valve closure time was measured in the superficial femoral and popliteal veins, with the values added together in each limb to give a total valve closure time (TVCT). A TVCT value greater than or equal to 4 seconds correlated best with severe phlebographic reflux, with a sensitivity of 90%, a specificity of 94%, and an accuracy of 93%. This value was confirmed as the best test for venous reflux by receiver operating characteristic curve analysis. Thus in the evaluation of patients with severe chronic venous insufficiency who are candidates for phlebography and surgery, quantitative duplex measurement of TVCT gives the best noninvasive assessment of the severity of deep venous reflux. (J Vasc Surg 1992;16:913–20.)

Section snippets

Patients

Patients were divided into three groups. Group N consisted of eight limbs in four normal healthy volunteers (three men and one woman; average age, 29.5 years). This group did not undergo ascending or descending phlebography. Group M consisted of those limbs that had mild (grade 0, 1, or 2) venous reflux as determined by descending phlebography (Table II).5

. Grading of reflux by descending phlebography

GradeDegree of reflux
0None
1Minimal; reflux to most proximal valve in SFV
2Mild; reflux to above

Results

Clinical stage by the Society for Vascular Surgery/International Society for Cardiovascular Surgery4 differed between those with mild phlebographic reflux and those with severe phlebographic reflux (Table III).Eight of 10 limbs in group S were clinical grade 3, whereas five of 10 limbs in group M were clinical grade 3. Incompetent perforating veins as defined by ascending phlebography were present in five of 10 limbs in group M and in six of 10 limbs in group S. The presence of incompetent

Discussion

Just as the severity of arterial insufficiency is manifested by the clinical condition—claudication, rest pain, and tissue loss—so is the severity of venous insufficiency—edema, pigmentation, liposclerosis, and ulceration. When the clinical condition as managed conservatively becomes intolerable to the patient, surgery should be considered. The decision to proceed with surgery may be aided by noninvasive tests. Invasive tests, however, provide the anatomic information crucial to selecting the

References (13)

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Reprint requests: Thomas F. O'Donnell, Jr., MD, Box 259, 750 Washington St., Tufts-New England Medical Center, Boston, MA 02111.

☆☆

J Vasc Surg 1992;16:913–20.

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