Valvular incompetence associated with venous ulceration can occur in the superficial, deep, or perforating systems. Duplex imaging was used to evaluate 95 extremities (78 patients) with current venous ulceration to determine the location of incompetence in each extremity. In addition, in 91 of the 95 extremities the area of the venous ulcer was evaluated for the presence of perforating veins or any other superficial veins or both conditions. Sixty-three (66.3%) of the 95 extremities had multisystem incompetence (superficial and perforating plus superficial and deep plus perforating and deep plus superficial and perforating and deep), whereas single system incompetence (superficial plus perforating plus deep) was seen in only 26 (27.3%). Isolated deep incompetence was identified in only two extremities (2.1%). Furthermore, 45% (41/91) of the ulcers had no duplex evidence of any venous abnormality in the ulcer bed. These data show that the site of valvular incompetence occurred in multiple locations, that isolated valvular incompetence of the deep venous system was uncommon, and that perforating veins were not always in the ulcer bed itself. Because standard venous surgery has traditionally been directed toward only one system, this may provide one explanation for ulcer recurrence. Therefore complete venous evaluation with duplex imaging allowing for surgical intervention directed specifically to the sites of involvement in each system is recommended.

The nature and distribution of venous disease surrounding the development of varicose veins and its treatment is controversial. Using duplex ultrasonography, we evaluated 54 lower extremities in 32 patients with varicose veins who were symptomatic and had obvious varicose veins by clinical examination. Twenty-eight percent had greater saphenous trunk incompetence, 2% had lesser saphenous trunk incompetence, and 96% had branch disease. Deep valvular incompetence was seen in 41%, saphenofemoral junction incompetence in 46%, and incompetence of one or more perforators in 46% of the extremities. Thirty-three percent demonstrated no evidence of associated saphenofemoral junction, deep vein, or perforating vein incompetence, while 20% had concurrent saphenofemoral junction, deep vein, and perforating vein incompetence. These data support the heterogeneity of venous disease seen in patients with varicose veins and suggest that surgical therapy be directed to a patient's specific pattern of incompetence rather than routine saphenofemoral junction ligation or stripping of the greater saphenous trunk.

Valvular incompetence associated with venous ulceration can occur in the superficial, deep, or perforating systems. Duplex imaging was used to evaluate 95 extremities (78 patients) with current venous ulceration to determine the location of incompetence in each extremity. In addition, in 91 of the 95 extremities the area of the venous ulcer was evaluated for the presence of perforating veins or any other superficial veins or both conditions. Sixty-three (66.3%) of the 95 extremities had multisystem incompetence (superficial and perforating plus superficial and deep plus perforating and deep plus superficial and perforating and deep), whereas single system incompetence (superficial plus perforating plus deep) was seen in only 26 (27.3%). Isolated deep incompetence was identified in only two extremities (2.1%). Furthermore, 45% (41/91) of the ulcers had no duplex evidence of any venous abnormality in the ulcer bed. These data show that the site of valvular incompetence occurred in multiple locations, that isolated valvular incompetence of the deep venous system was uncommon, and that perforating veins were not always in the ulcer bed itself. Because standard venous surgery has traditionally been directed toward only one system, this may provide one explanation for ulcer recurrence. Therefore complete venous evaluation with duplex imaging allowing for surgical intervention directed specifically to the sites of involvement in each system is recommended.