1. COLOUR FLOW DUPLEX IMAGING IN VENO-LYMPHATIC ULCER A. Cavezzi S.Benedetto del Tronto, Bologna www.cavezzi.it

3. PHLEBO-LYMPHOPATHIC ULCER Causes: - Secondary Deep Venous Insufficiency (Post-thrombotic syndrome) or Primary Deep Venous Insufficiency - Secondary Deep Venous Insufficiency (Post-thrombotic syndrome) or Primary Deep Venous Insufficiency - Superficial Venous Insufficiency - Functional Venous Insufficiency: Muscle- Vascular Pump dysfunction, obesity, etc. - Lymphatic Dysfunction

4. Serious Post-Thrombotic Syndrome with reflux in femoral, popliteal and tibial veins  supra-malleolar ulcer

6. Magnusson et al EJVES 2001

7. LITERATURE DATA LITERATURE DATA A)Metanalysis 1980-1998 (1249 limbs with venous ulcers) * 92% with reflux, 8% without reflux * 45% reflux only in SVS, 12% reflux only in DVS, 43% reflux in SVS and DVS (Tassiopoulos AK, Golts E, Oh DS, Labropoulos N., EJVES ) B)L’incompetence of popliteal vein is a negative prognostic factor for ulcer healing (42 vs 10% ) ( Brittenden J, Bradbury AW, Allan PL, Prescott RJ, Harper DR, Ruckley CV, Br J Surg) C) Limbs with venos ulcer, in confrontation with healthy limbs, have a decreased ejection fraction and an increased post-exercise residual (pump dysfunction..) (Araki CT, Back TL, Padberg FT, Thompson PN, Jamil Z, Lee BC, Duran WN, Hobson RW; J Vasc Surg)

8. CFDI AND SECONDARY DEEP VENOUS INSUFFICIENCY - POST-THROMBOTIC SYNDROME - - possible persistent occlusions (8%) - reflux due to post-thrombotic valvular incompetence (33% isolated, 50% with thrombotic sub-occlusive changes) - morphologic and functional state of saphenous stems and of perforators - dilatation of collateral branches

9. POST-THROMBOTIC SYNDROME

10. S.P.T.: DIFFERENZA ECOGRAFICA TESSUTI IN SEDE SOPRA (SX) ED ENTRO (DX) DISTROFIE CUTANEE S.P.T. - Stenosi V. Iliaca Esterna

12. POST-THROMBOTIC SYNDROME: SYSTOLIC REFLUX OF SPJ AND ACTIVATION OF A SHUNT WITHIN GIACOMINI VEIN OR WITHIN SMALL SAPHENOUS VEIN Refl e/o Ostruz

13. ENLARGEMENT OF GIACOMINI VEIN IN POST-THROMBOTIC SYNDROME (PERSISTENT STENOSIS OF POPLITEAL VEIN AND SUPERFICIAL FEMORAL VEIN)

14. CFDI AND SUPERFICIAL VENOUS INSUFFICIENCY - Reflux/Retrograde flow in saphenous stems - Incompetence of saphenous junctions or extra-junction refluxes - Morphologic and haemodynamic state of perforators -Patency and competence of deep veins

16. DISTRIBUZIONE SEGMENTARIA DEL REFLUSSO NELLA VGS 15 % 30 % 52 % 3 %

17. FROM BJORDAL ….1971…..

18. PERFORATING VEINS : THEIR ROLE IN PRIMARY VARICOSE VEINS In primary varicose veins the majority of PV in the leg has a main or single role of re-entry in the deep venous systemIn primary varicose veins the majority of PV in the leg has a main or single role of re-entry in the deep venous system Bi-directional flow in PV means incompetence, but not always pathogenicity: in the “terminal” PVs of the leg the balance (the net flow) of the bi-directional flow in the systolic phase (calf contraction) and in the diastolic phase (calf relaxation) is largely in favour of the re-entry in the DVS: the PV may be incompetent, but it is not pathologic …Bi-directional flow in PV means incompetence, but not always pathogenicity: in the “terminal” PVs of the leg the balance (the net flow) of the bi-directional flow in the systolic phase (calf contraction) and in the diastolic phase (calf relaxation) is largely in favour of the re-entry in the DVS: the PV may be incompetent, but it is not pathologic … (Perthes, Bjordal, Bassi, Tibbs, Franceschi etc.)

19. BASIC KNOWLEDGE ABOUT PERFORATORS BASIC KNOWLEDGE ABOUT PERFORATORS a) healthy subjects may have bi-directional flow (which were traditionally considered as pathologic in the past literature ) in 20-30% of the limbs (Coleridge- Smith et al.) b) up to 50% of the perforators in the calf have NO valves…., thus favoring an inflow or an outflow according to the pressure gradients in the superficial and deep venous compartments (Several old and new anatomic studies)

21. REFLUX MOVES FROM LSV TO A TRIBUTARY AND IT FINALLY RE-ENTERS IN THE DEEP VENOUS SYSTEM THROUGH A LARGE (5 MM DIAMETER ) RE-ENTRY PERFORATOR MINIMAL OUTWARD FLOW DURING MUSCLE COMPRESSION (SYSTOLE) AND REMARKABLE INWARD FLOW DURING MUSCLE RELAXATION (DIASTOLE)

22. COLOUR-DUPLEX INVESTIGATION IN ULCER AREA

23. CFDI EVALUATION OVER ULCER AREA Rare incompetent perforators….

24. PRIMARY DEEP VENOUS INSUFFICIENCY - Reflux in deep veins - Reflux of saphenous veins - No findings compatible with previous DVT (thrombotic changes etc.) - Generalised Dilatation of deep veins -Incidence ???????

27. ABOLITION OF DEEP VEIN REFLUX AFTER SURGERY / SCLEROTHERAPY OF SMALL SAPHENOUS VEIN

28. Small Saphenous Vein Incompetence and Deep Vein Reflux Author /year Inc.DVS Method Author /year Inc.DVS Method Somjen / 1992 52% D Somjen / 1992 52% D Hauser / 1993 86% D+Phleb. Hauser / 1993 86% D+Phleb. Sakurai / 1997 44,9% (SFJ incl.) CD Sakurai / 1997 44,9% (SFJ incl.) CD Brunner / 1997 68,7% D+Phleb Brunner / 1997 68,7% D+Phleb Daher / 2001 39,7%D Daher / 2001 39,7%D Recek / 2002 100%D Recek / 2002 100%D

29. INCOMPETENCE OF SAPHENO-POPLITEAL JUNCTION AND DEEP VEIN REFLUX - Personal Experience - 162 limbs submitted to SSV surgery 162 limbs submitted to SSV surgery Pre-op: 124 limbs (76%) retrograde flow in lower tract of superficial femoral vein and in popliteal vein (mainly upper and medium tract) Pre-op: 124 limbs (76%) retrograde flow in lower tract of superficial femoral vein and in popliteal vein (mainly upper and medium tract) Post-op: 95 limbs (77%) without retrograde flow in DVS, 27 limbs (21%) with retrograde flow lasting less than 1 sec., 2 limbs with persistent retrograde flow in DVS Post-op: 95 limbs (77%) without retrograde flow in DVS, 27 limbs (21%) with retrograde flow lasting less than 1 sec., 2 limbs with persistent retrograde flow in DVS (Cavezzi, Tarabini, Collura, Sigismondi, Barboni, Carigi; Phlébologie 2002 )

30. THE UNBEARABLE HEAVINESS OF BEING (M.Kundera revisited) … Functional Venous Insufficiency with Veno- Lymphatic Ulcer

31. “Seriously affected legs (previous massive ulcerations, actual skin changes, phlebolymphoedema etc.) in absence of whichever organic venous or lymphatic disease: psychopathologic patient who lives nearly 20 hours a day standing still…: MUSCLE-VENOUS PUMP DYSFUNCTON….