December 23, 2005

Primary Versus Ilio-femoral Post-thrombotic Chronic Venous Disease: CEAP Clinical Class, VCSS and Hemodynamic Disparity.

Konstantinos T. Delis, MSc, MD, MS, PhD, FRCSI, Veronica Ibegbuna, BSc, PhD, Y M. Kan, FRCS, Dimitris Bountouroglou, MSc, FRCS.
St. Mary's Hospital, Paddington, London, United Kingdom.

Objective Post-thrombotic venous disease has been associated with complications more often refractory to treatment than primary chronic venous disease (CVD). However, comparative clinical and hemodynamic data between primary and chronic post-thrombotic iliofemoral venous disease are unavailable. We determined the venous hemodynamics, clinical severity score (VCSS) and CEAP clinical status in patients with chronic ilio-femoral thrombosis in comparison with those in patients with primary CVD.
Methods 35 consecutive patients with a history of ilio-femoral thrombosis treated originally with anticoagulation, leg elevation and elastic compression [16 men, 19 women; age median 46 years (iqr, 38-54)], and 70 patients with primary CVD [28 men, 42 women; age median 44 years (iqr, 34-58)] referred consecutively to the vascular laboratory for non-invasive investigation had their venous hemodynamics estimated with duplex ultrasound and air-plethysmography. The CEAP clinical class of the limbs and VCSS were determined. Assessment of hemodynamics included the venous outflow (Outflow-fraction[OF]), venous-volume[VV], calf muscle pump function (Ejection-Fraction[EF] and Residual-Volume-Fraction[RVF]) and the amount of venous reflux (Venous-Filling-Index[VFI]). Excluded were patients with peripheral arterial disease (ABI<1.0), symptomatic heart disease, peripheral edema of unrelated causes, lymphedema and limb trauma. In patients with bilateral CVD only the limb with worse clinical class (or VCSS, in same CEAP classes) was selected for analysis. Results are reported as median and interquartile range[iqr]. Statistical analysis was performed with the Mann-Whitney test (point estimate and 95%CI).
Results There was no age difference between the two study groups. Duration of disease was 10 (5.5-20) years in limbs with primary CVD and 5 (2-8) years in limbs with prior ilio-femoral thrombosis (p<0.01). Superficial and deep (± perforator) reflux occurred in 37% (26_/70) of limbs with primary CVD and 71% (25_/35) of limbs with chronic iliofemoral venous disease; superficial (± perforator) reflux was documented in 44_/70 (63%) and 10_/35 (29%) of limbs, respectively (p<0.01).


Patients with	OF (%)	VV (mls)	EF (%)	RVF (%)	VFI (ml/sec)	CEAP Class	VCSS
Ilio-femoral Thrombosis	37 32-45	98.5 87.5-132	49 40-60	45 36.5-53	3.65 2.5-5.8	3 3-4	6 3-7
Primary CVD	48 42-54	117 88-139	56 49-67	32 21-41	3.65 1.85-6.3	2 2-3.75	3 1-5
P-value	=0.019	=0.36	=0.021	=0.0009	=0.53	=0.049	=0.007
Point Estimate	10	-	7	11	-	1	2
95%CI	2-19	-	1-13	5-17	-	0-1	1-3

Conclusion Within a median 5 years of the disease onset, limbs with chronic ilio-femoral thrombosis had a worse CEAP clinical class and VCSS score of venous disease than limbs with primary CVD of 10 years median span. The faster progression of CVD in limbs with ilio-femoral thrombosis was associated with attenuation of the calf muscle pump efficiency and elevation of the residual (post-exercise) venous volume, amidst outflow obstruction and marked venous valvular incompetence, although the amount of reflux was not worse than that in limbs with primary CVD.

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