Great saphenous vein stripping with preservation of sapheno-femoral confluence: hemodynamic and clinical results

BACKGROUND: Radiofrequency and laser vein treatment, which entail preservation of the saphenous confluence, have called into question the dogma of ligation of all tributaries at the sapheno-femoral confluence (SFC), so called "crossectomy". Nevertheless, crossectomy is still done when saphenous vein stripping is chosen for varicose vein treatment. The purpose of this study was to evaluate results after stripping procedures in which the SFC was preserved. METHODS: This was a retrospective cohort study for which limbs treated for varicose veins by surgical stripping of the great saphenous vein and preservation of the SFC were studied. All limbs had a preoperative duplex examination and showed SFC and truncal incompetence of the great saphenous vein. Periodic postoperative standing duplex ultrasound and clinical examinations were carried out, and results were recorded and analyzed retrospectively. RESULTS: A total of 195 lower limbs were operated on in 151 patients (128 women and 25 men) aged from 22 to 88 years (mean age 56.8). The preoperative diameter of the SFC ranged from 4.7 to 17 mm (mean 9.5 mm). The preoperative CEAP class distribution was C1 1.5%, C2 82.1%, C3 6.7%, and C4-C6 9.7%. Preoperative symptoms were present in 61.8% of cases. Postoperative thrombosis of the SFC was observed in one case with an extension to the deep femoral vein and pulmonary embolization at 1 month. Recovery was complete. At a mean of 24.4 months postoperatively (median 27.3 months, range 8 to 34.8), persistent SFC reflux was observed in only two cases (1.8%) and a SFC neovascularization in one case (0.9%). Recurrence of varicose veins appeared in seven cases (6.3%) but in conjunction with SFC reflux in only one case. Post treatment 83.9% of limbs were converted to CEAP clinical class 0 to 1 and significant symptom improvement was observed in 91.3% of cases with an aesthetic benefit in 95.5%. CONCLUSION: Preservation of the SFC during saphenous stripping gave good results with regard to hemodynamics and neovascularization on the SFC, varicose vein recurrence, improvement of symptoms, and aesthetic appearance for legs with a median follow-up of 27.3 months.     

Duplex ultrasound scan findings two years after great saphenous vein radiofrequency endovenous obliteration

OBJECTIVE: To assess the clinical and duplex ultrasound scan findings in the groin and thigh 2 years after great saphenous vein (GSV) radiofrequency endovenous obliteration (RFO). METHODS: Sixty-three limbs in 56 patients with symptomatic varicose veins and GSV incompetence were treated with RFO, usually with adjunctive stab-avulsion phlebectomies, and examined at a median follow-up of 25 months, by using a color-coded, duplex sonography protocol that mandated views in at least two planes of the saphenofemoral junction (SFJ) and its tributaries and at three GSV levels in the thigh. RESULTS: The commonest duplex finding in the groin was an open, competent, SFJ with a < or =5-cm patent terminal GSV segment conducting prograde tributary flow through the SFJ (82%). Despite the presence of a total of 104 patent junctional tributaries, SFJ reflux was uncommon, affecting only five limbs. GSV truncal occlusion was observed in 90% of treated GSVs. Limited segmental treatment was successful in three limbs with a midthigh reflux source well below competent terminal and subterminal valves. Six GSV trunks had partial or no occlusion, but only one refluxed. These were anatomical RFO failures (9.5%) but were clinically improved, including the refluxing limb. Neovascularity was not identified in any groin. Thigh varicosities were observed in 12 limbs, including telangiectasias and isolated small tributary branches. New varicosities, linked to refluxing thigh perforators (two), or patent SFJ tributaries (three), were present in five limbs. CONCLUSION: RFO is the ideological opposite of high ligation without GSV stripping. It leaves physiologic tributary flow relatively undisturbed, does not incite groin neovascularity, eliminates the GSV as a refluxing conduit in >90% of limbs and has a 2-year, postadjunctive phlebectomy varicosity prevalence of 7.9%, with symptom score improvement in 95% of limbs with an initial score higher than zero.     

Age-related variations of varicose veins anatomy

BACKGROUND: Primary varicose veins are commonly considered a progressive disease starting from the saphenous junctions and extending to tributaries in a retrograde fashion along the saphenous trunks. This theory has been criticized by studies indicating different patterns of development and progression of varicose veins. To contribute to the understanding of the pathogenesis of the disease, the anatomy of the venous bed was comparatively evaluated by duplex sonography in patients with varicose veins with a marked difference in age. METHODS: The study included 100 varicose limbs in 82 patients aged < 30 years and 238 limbs in 183 patients aged > 60 years. Veins were designated as saphenous veins (SVs), tributaries of the SVs (STVs), and veins not connected with the SVs (NSVs). Four main anatomic patterns were comparatively evaluated: (1) varicose changes only along SVs, (2) varicose changes along SVs and STVs, (3) varicose changes only in STVs, and (4) varicose changes only in NSVs. RESULTS: SVs were normal in 44% of varicose limbs. In most limbs from young subjects, varicose changes afflicted only SVTs (25%) and NSVs (36%). Varicose SVs were more frequent in the older group (62%) than in younger one (39%) owing to a higher prevalence of limbs with combined SV and STV varicosities (respectively, 59% and 37%). In the older group, varicosities in the STVs were more frequently observed in association with incompetence of the SV trunks. CONCLUSION: The frequent occurrence of normal SVs in varicose limbs of all patients does not support the crucial role commonly credited to SVs in the pathogenesis of primary varicosities. Moreover, the SV trunks were normal in most varicose limbs from young patients. These findings suggest that varicose disease may progressively extend in an antegrade fashion, spreading from the STVs to the SVs. This hypothesis suggests that the saphenous trunks could be spared in the treatment of a relevant number of varicose legs. Prospective longitudinal studies with serial duplex evaluations of large series of extremities are necessary to confirm this hypothesis.     

Neovascularization: an "innocent bystander" in recurrent varicose veins

OBJECTIVE: Varicose vein recurrence after surgery occurs in up to 60% of patients. A variety of technical factors have been implicated, but biological factors such as neovascularization have more recently been proposed. The objective of this study was to characterize the relative contribution of technical and biological factors to recurrence in a large prospective series of recurrent varicose veins. METHODS: Duplex and operative findings were recorded prospectively in a consecutive series of 500 limbs undergoing surgery for recurrent varicose veins between 1995 and 2005 in a university teaching hospital. Only limbs with previous saphenofemoral junction surgery were included. All limbs had preoperative duplex mapping by an accredited vascular technician who assessed the status of the great saphenous vein (GSV) in the thigh and groin, sought sonographic evidence of neovascularization, and reported on the presence of reflux in the short saphenous vein and perforator sites (typical and atypical). All operations were performed with an attending vascular surgeon as the lead operator. RESULTS: Primary GSV surgery was incomplete in 83.2% of limbs. A completely intact GSV system was present in 17.4% of limbs. An incompetent thigh saphenous vein was present in 44.2% of limbs, 37.6% had GSV stump incompetence with one or more intact tributaries, and 16% had both a residual thigh GSV and an incompetent stump with intact tributaries. Non-GSV sites of reflux were identified in 25% of limbs. Neovascularization was identified on duplex scanning in 41 (8.2%) limbs. However, in 27 of these, surgical exploration revealed a residual GSV stump with 1 or more significant tributaries. Each of the remaining 14 (2.8%) limbs had a residual incompetent thigh GSV. CONCLUSIONS: Despite reports to the contrary, neovascularization occurs in a relatively small proportion of patients with recurrent varicose veins. All recurrent varicose veins associated with duplex-diagnosed neovascularization are also associated with persistent reflux in the GSV stump tributaries, thigh GSV, or both. Recurrence after primary varicose vein surgery is associated with inadequate primary surgery or progression of disease, and neovascularization alone is not a cause of recurrent varicose veins.     

Sapheno-femoral Junction Reflux in Patients with a Normal Saphenous Trunk

OBJECTIVE: To determine the patterns and clinical importance of saphenofemoral junction (SFJ) reflux in patients with chronic venous disease (CVD) and a normal great saphenous vein (GSV) trunk. METHODS: Fifteen hundred consecutive patients were examined using duplex ultrasound (DU) in three centres. Patients with reflux involving the SFJ and/or its tributaries only were included and its prevalence and patterns were studied. Patients with GSV trunk reflux or in any other veins were excluded. The SFJ diameter was categorised as normal, dilated or varicose. The results of surgery were evaluated by DU in 42 patients 1 year after the procedure. RESULTS: SFJ area incompetence with a competent GSV trunk occurred in 8.8% of limbs. It was significantly more common in CEAP class 2, 13.6% compared to class 3, 8.2% (p=0.03), class 1, 2.7%, class 4, 4.4% and classes 5 and 6 together, 1.5% (p<0.001 for all). The SFJ had a normal diameter in 21%, dilated in 62% and varicose in 17%. Reflux was seen in 39% of limbs with a normal SFJ diameter, in 85% of those with a dilated SFJ and in all varicose SFJs. Of the 42 operated limbs, 27 had ligation and division of the SFJ and tributary phlebectomies. Fifteen had tributary phlebectomies only, leaving the SFJ intact. At one-year follow-up, SFJ area reflux was found in six limbs (14.3%), involving the SFJ alone in 1, a main tributary in 1 and 4 small tributaries. No reflux was found in the GSV trunk. All but two of the 42 patients were satisfied with the results. CONCLUSIONS: SFJ reflux with tributary involvement and sparing of the GSV trunk occurs in 8.8% of CVD patients. Such reflux is found in the entire spectrum of CVD, but it is more common in class 2. Local surgery with or without SFJ ligation has very good results at 1 year. DU scanning prior to treatment is important in all patients so that the intact GSV can be spared.     

Primary superficial vein reflux with competent saphenous trunk.

OBJECTIVES: because reflux in superficial vein tributaries is most often collectively reported with the main saphenous veins, its importance remains largely unrecognised. This study was designed to identify the distribution and extent of non-truncal superficial venous reflux and its association with the signs and symptoms of chronic venous disease (CVD). PATIENTS AND METHODS: eighty-four limbs in 62 patients with signs and symptoms of CVD and evidence of reflux on continuous-wave Doppler were subsequently examined with colour-flow duplex imaging. Incompetent superficial vein tributaries were imaged throughout their extent and both ends were identified. Limbs with reflux in the main trunk of the saphenous veins or the deep, perforator or muscular veins, superficial or deep vein thrombosis, injection sclerotherapy, varicose-vein surgery, arterial disease and inflammation of non-venous origin were excluded from the study. The CEAP classification system was used for staging clinical severity of CVD. RESULTS: the prevalence of tributary reflux alone was 9.7% (84/860). Reflux was detected in 171 tributaries. The number of incompetent tributaries ranged from 1 to 5 per limb. Most prevalent were the tributaries to the greater saphenous (111, 65%<0. 0001), followed by those of lesser saphenous (33, 19%) or a combination of both (12, 7%). Incompetent non-saphenous tributaries were uncommon (15, 9%). Among the named tributaries in the lower limb the posterior arch vein was most often incompetent (46, 27%) followed by the anterolateral vein of the thigh (30, 18%), the medial accessory vein (16, 9%) and the anterior arch vein (14, 8%). Reflux in above-the-knee tributaries alone was found in 18 limbs (21%), in below the knee in 23 (28%) and in both sites in 43 (51%). The vast majority of the limbs (71%,p <0.0001) belonged to CVD class 2, 14% in class 3, 9% in class 1 and only 6% in class 4. Class 3 and 4 patients tended to have a longer duration of signs and symptoms, higher number of incompetent tributaries per limb and also a higher prevalence of combined above- and below-knee reflux. CONCLUSIONS: these data indicate that reflux confined to superficial tributaries is found throughout the lower limb. Because this reflux is present without greater and lesser saphenous trunk, perforator and deep-vein incompetence or proximal obstruction, it shows that reflux can develop in any vein without an apparent feeding source. Greater saphenous tributaries are affected significantly more often than those of lesser saphenous, while non-saphenous reflux is uncommon. Most limbs have signs and symptoms of CVD class 2 and 15% belong in classes 3 and 4.     

Selective stripping operation based on Doppler ultrasonic findings for primary varicose veins of the lower extremities

In 337 limbs (208 patients) with primary varicose veins, Doppler ultrasound was used to detect reverse flow in the saphenous veins caused by manual compression of the calf. According to the extent of reverse flow in the saphenous trunks, varicosities of the long saphenous vein were classified into five types and the short saphenous vein, into four types. Two hundred five (66.3%) of 309 limbs with varicosities of the long saphenous vein had reverse flow in the entire saphenous trunk from the groin to the ankle. In varicosities of the short saphenous vein, 37 (52.9%) of 70 limbs showed reverse flow from the popliteal fossa to the ankle. The other limbs demonstrated reverse flow only in some segments of the saphenous veins. On the basis of these Doppler ultrasonic findings, selective stripping operations were performed on 80 limbs, in which only the segments with venous reverse flow were selectively removed. Postoperative plethysmographic measurement of the venous reflux volume and follow-up studies showed that results of the selective stripping operations were as satisfactory as those of the standard stripping operations (189 limbs) in which the entire saphenous vein was removed. Furthermore, the selective stripping operation was advantageous in reducing the incidence of nerve injury.     

Causes and treatment of recurrent varices of the lower limbs

Recurrence of varicose veins following surgery is a common, complex and costly problem in vascular surgery. The aims of our study were to determine the causes of recurrent varicose vein disease, to compare the preoperative duplex ultrasound findings with surgical findings, and to evaluate the efficacy of our surgical policy. We retrospectively studied 49 limbs operated on for recurrent varicose veins. All patients were monitored 6 weeks and 6 months after surgery and then underwent clinical examination in June 2005. Preoperative duplex ultrasound showed 100% specificity and 97% sensitivity. The patients were operated on for recurrence 152.2 +/- 95.5 months after the primary operation. The incidence of postoperative minor complications was 8.1% and of re-recurrence 10.2%. In 73.5% of patients during surgical re-exploration of the groin we found one or more tributaries of the great saphenous vein/common femoral vein, producing reflux. In 90.1% of cases we also treated incontinent perforator vessels. We recommend surgical re-exploration of the sapheno-femoral venous junction and thorough preoperative study of the perforator vessels in all patients with recurrent varicose veins.     

Nonsaphenous superficial vein reflux.

BACKGROUND: Information on nonsaphenous superficial venous reflux is lacking. This study was designed to determine the prevalence of reflux in nonsaphenous veins, their association and correlation with risk factors, and signs and symptoms of chronic venous disease (CVD). METHODS: Information on 835 limbs in patients with signs and symptoms of CVD were prospectively entered into a customized database. These patients had been referred from the venous clinic to the vascular laboratory for color-flow duplex scanning evaluation of the lower-limb veins. All patients were examined for reflux in the standing and sitting positions. Nonsaphenous reflux was defined as that in superficial veins that are not part of the greater or lesser saphenous systems. Particular attention was paid to the patterns of reflux and anatomy of the nonsaphenous veins from the proximal to the distal ends, including their connections with the saphenous and deep veins. RESULTS: Nonsaphenous venous reflux was found in 84 limbs (10%) of 72 patients, 67 of whom were women. The mean number of pregnancies in these patients was higher than that of 100 randomly selected women with saphenous reflux (3.2 vs 2.2). According to CEAP classification, 90% of the limbs were in CVD classes 1 through 3 and only 10% had skin damage (classes 4-6). Symptoms were present in 67 limbs (80%). Forty-two limbs (50%) had reflux in tributaries of lateral, posterior, and medial thigh. These veins were connected with perforators uniting with the deep femoral, femoral, and muscular veins of the thigh in 36 limbs. Reflux in these perforators was detected in 19 limbs. Reflux arising from the pelvic veins was found in 29 limbs (34%), 18 of which were from vulvar veins medial to saphenofemoral junction and 11 of which were from veins in the gluteal area. Incompetent veins from the sciatic nerve were found in nine limbs (10%). Reflux in the vein of the popliteal fossa was found in seven limbs (8%). Reflux in knee tributaries was detected in three limbs (4%), two of which were connected with posterolateral knee perforators and one with the posterior tibial nerve veins. CONCLUSIONS: The prevalence of nonsaphenous reflux in our practice was 10%. The vast majority of these patients (93%) were women with a mean of 3.2 pregnancies. Ninety percent of these limbs have signs and symptoms assigned to CVD classes 1 to 3. These data may simply reflect the referral pattern, but also a possible association with female sex and number of pregnancies. The unusual anatomy of these veins stresses the importance of color-flow duplex scanning before surgery.     

Prevalence and clinical significance of posterolateral thigh perforator vein incompetence

Purpose: Posterolateral thigh perforator (PLTP) veins are part of the lateral thigh venous system, which in most people remains undeveloped. This study was designed to determine the prevalence and clinical significance of these veins.Methods: Over the past 6 years, 2820 lower limbs with signs and symptoms of chronic venous disease (CVD) were evaluated for venous reflux using color flow duplex imaging. Superficial, perforating, and deep veins were examined in the standing, sitting, and reversed Trendelenburg positions. PLTP veins were best identified in the standing position with the patient facing away from the examiner.Results: Twenty-six incompetent PLTP veins were found in 24 limbs (0.85%) of 21 patients (mean age, 43 ± 16 years; range, 22 to 77 years). All PLTP veins pierced the fascia lata 12 to 25 cm (mean, 16 ± 3 cm) above the popliteal skin crease in the lateral aspect of the thigh. At this level, the PLTP veins dove posteriorly 3 to 8 cm to join primarily tributaries of the deep femoral vein, superficial femoral vein, or both. Eight PLTP veins were duplicated at 1 to 2 cm below the fascia. Seven PLTP veins gave rise to superficial tributaries that were extended to the lower lateral and posterior thigh, whereas the remaining 19 PLTP veins gave rise to tributaries alongside the lesser saphenous vein and the anterior arch of the greater saphenous vein. On nine occasions, reflux was found in the PLTP veins and their associated tributaries alone. In all of these cases, reflux was adequately controlled with a tourniquet placed distal to the fascial defect. In the remaining 17 PLTP veins, reflux was also seen in the greater saphenous vein, the lesser saphenous vein, or both. None of the limbs that had PLTP vein reflux alone exceeded CVD class 3. When PLTP vein reflux was combined with saphenous reflux, there were five limbs classified as CVD class 4 and one limb each as CVD classes 5 and 6. Twenty limbs underwent ligation and stripping of the varicosities. Three of the earlier patients in the series underwent incomplete operations, which resulted in immediate residual varicosities from the PLTP tributaries. All three patients underwent reoperation successfully within a year.Conclusions: The prevalence of PLTP vein reflux is quite low. Reflux in the PLTP veins alone is associated with mild to moderate clinical presentation. However, when it is combined with saphenous reflux skin damage can be present. Failure to recognize PLTP veins may result in an incomplete or unnecessary operation, leaving the patients with residual varicose veins. (J Vasc Surg 1997; 26:743-8.)     

Preoperative assessment of primary varicose veins: a duplex study of venous incompetence.

OBJECTIVES: we investigated the importance of preoperative duplex scanning in primary uncomplicated varicose vein surgery by evaluating the incidence of superficial venous imcompetence and significant anatomical variations that may be difficult to detect clinically and therefore might be expected to contribute to recurrence. DESIGN: a retrospective study of a prospectively collected database. MATERIALS: over 15 consecutive months, patients attending the non-invasive vascular laboratory for duplex scanning of their primary uncomplicated varicose veins were assessed. METHODS: vascular laboratory case notes were assessed and incidence of superficial venous incompetence and any significant anatomical variations that would have been difficult to detect clinically +/-HHD were documented. Any correlation with clinical findings was also evaluated. RESULTS: a total of 223 limbs (176 patients) were assessed. Sixty-seven limbs (30%) in fact had a competent sapheno-femoral junction. Sixty-one limbs (27%) had pure sapheno-femoral reflux and nil else. Fifty-three limbs (24%) had significant anatomical variations. Forty-two limbs (19%) had short saphenous vein incompetence, of which 67% were clinically unsuspected. CONCLUSIONS: preoperative duplex scanning is indicated in all patients with uncomplicated primary varicose veins if appropriate venous surgery is contemplated. There are obvious resource and recurrence rate implications. Further evaluation in the form of randomised trials are required.     

Role of superficial venous surgery in patients with combined superficial and segmental deep venous reflux.

OBJECTIVES: superficial venous surgery heals chronic venous ulceration (CVU) in the majority of patients with isolated superficial venous reflux (SVR). This study examines the role of superficial venous surgery in patients with combined SVR and segmental deep venous reflux (DVR). METHODS: combined SVR and segmental DVR was diagnosed by venous duplex in 53 limbs in 49 patients (24 men and 25 women of median age 66, range 27-90, years). Fourteen limbs had varicose veins (CEAP class 2-4) and 39 (74%) had active CVU (CEAP class 6). Duplex ultrasound was performed before and three months after local anaesthetic superficial venous surgery. Perforator vein surgery, skin grafting and compression bandaging or hosiery were not used. RESULTS: forty-two limbs with long saphenous vein (LSV) reflux underwent sapheno-femoral disconnection, 10 with short saphenous vein (SSV) reflux underwent sapheno-popliteal disconnection and one limb with LSV and SSV reflux had sapheno-femoral and sapheno-popliteal disconnection. Segmental DVR was confined to the superficial femoral vein (SFV) in 16 limbs, below knee popliteal vein (BKPV) in 25 and gastrocnemius vein (GV) in 12 limbs. Overall, duplex demonstrated post-operative resolution of segmental DVR in 26 of 53 (49%) limbs. Resolution of segmental SFV reflux occurred in 12 of 16 (75%) limbs compared with 14 of 37 (38%) limbs with segmental BKPV or GV reflux (p=0.018). Segmental DVR resolved in 19 of 39 (49%) limbs with CVU and ulcer healing occurred in 30 of 39 (77%) limbs at 12 months with a median time to healing of 61 (range 14-352) days. Segmental DVR resolved in 14 of 30 (47%) limbs with a healed ulcer: 7 of 9 (78%) limbs with SFV and 7 of 21 (33%) with BKPV or GV reflux (p=0.046). CONCLUSIONS: these data demonstrate that in patients with combined SVR and segmental DVR, superficial venous surgery alone corrects DVR in almost 50% of limbs and is associated with ulcer healing in 77% of limbs at 12 months. These findings suggest an extended role for superficial venous surgery in the management of patients with complicated venous disease.     

Foam sclerotherapy combined with surgical treatment for recurrent varicose veins: short term results.

OBJECTIVE: To study the short term results of combined peroperative foam sclerotherapy (PFS) and surgical treatment for recurrent varicose veins. METHODS: PFS was used to treat 129 limbs with recurrent varices: 100 great saphenous (GSV), 29 small saphenous veins (SSV). Foam was prepared with 1% polidocanol mixed with 4 times its volume of air. The 100 GSVs comprised 28 trunks directly connected with the femoral vein, 28 connected to a lymph node venous network, 11 associated with perforators and 33 isolated trunks. The 29 SSVs comprised 4 trunks directly connected to the popliteal vein, 7 isolated trunks, 15 popliteal perforators and 3 recanalisations after SSV stripping. All operations included phlebectomies. In twenty limbs re-ligation of the SFJ and 4 SPJs was carried out. All were performed under local anaesthesia in an ambulatory setting. Patients were assessed clinically and by colour duplex ultrasound after 3 and 40 days follow-up. RESULTS: 120 patients (93%) showed complete obliteration of saphenous trunks, junctions and varices. The 9 incomplete obliterations were 3 venous recanalisations in the SSV compartment and 6 perforators (4 popliteal and 2 femoral). Two asymptomatic deep venous thromboses were detected by colour duplex 3 days after operation. CONCLUSION: PFS facilitates surgical treatment of recurrent varicose veins. There is a small risk of post-operative deep vein thrombosis.     

Presentation of the patient with recurrent varices after surgery (REVAS)

AIM: To identify in patients with recurrent varices after surgery (REVAS) the clinical, etiologic, anatomic, and pathophysiologic patterns according to the CEAP classification, as well as the site, source, causes of recurrence, and contributory factors by using the REVAS classification. METHODS: Centers from eight countries enrolled patients with superficial vein reflux that had had a previous operation. A physical examination and a duplex ultrasound scan were performed at the first visit. This was repeated between 2 to 8 weeks after by the same physician and by another physician within the same time frame. The perforator, deep, and superficial veins systems as well as their accessories and tributaries were examined. A form based on the CEAP and the REVAS classification was used and the data were entered in a customized database. RESULTS: Fourteen institutions enrolled 170 patients (199 lower limbs) in 1 year. Their mean age was 56 years, and 69% were women. Most of them had undergone one surgical procedure before enrollment (76.6%). Most had varicose veins and swelling (70.9%), and the rest had skin damage (29.1%). More than 90% had primary etiology. The saphenofemoral junction (47.2%) and leg perforators (54.7%) were the areas most often involved by recurrent reflux. Reflux in deep veins was detected in 27.4%. Class 2 (varicose veins) alone was present in 24.6% of limbs, two classes were present in 43%, and three in 24%. Neovascularization was as frequent as technical failure (20% vs 19%); both were seen in 17%. In 35%, the cause was uncertain or unknown. When recurrence occurred at a different site, development of reflux in new sites was found in 32% of limbs. Of the contributing factors, family history and lifestyle had the highest prevalence. Women had significantly more procedures than men, despite a clear trend toward more severe disease in the latter. CONCLUSIONS: Most patients were symptomatic with several clinical forms of presentation. The REVAS classification, together with CEAP, gives significant and more appropriate information for evaluating and following-up patients with chronic venous disease who have had an intervention.     

Prevalence, anatomic patterns, valvular competence, and clinical significance of the Giacomini vein

OBJECTIVE: Coursing the posterior thigh as a tributary or trunk projection of the small saphenous vein (SSV), the Giacomini vein's clinical significance in chronic venous disease (CVD) remains undetermined. This cross-sectional controlled study examined the prevalence, anatomy, competency status, and clinical significance of the Giacomini vein across the clinical spectrum of CVD in relation to the SSV termination. METHODS: One hundred eighty-nine consecutive subjects (301 limbs) with suspected CVD (109 men, 80 women; age, 18-87 years [median, 61 years]) underwent examination, clinical class (CEAP) stratification, and duplex ultrasound determination of the sites and extent of reflux >0.5 sec) and Giacomini vein's anatomy. RESULTS: A Giacomini vein was found in 70.4% of limbs (212 of 301; 95% confidence interval, 65%-75.6%). Extent, pattern, and sites of reflux in all named superficial and deep veins were evenly distributed in limbs with and without a Giacomini vein; perforator vein incompetence in thigh and calf was also balanced (all, P > .2). Giacomini vein had no effect ( P > .2) on SSV termination anatomy, displaying a similar prevalence in classes C(0-6) . In 212 limbs, either as a tributary or trunk projection of the SSV, the Giacomini vein ascended subfascially (n = 210) to the lower (8%; n = 17), middle (47.6%; n = 101), or upper (44.3%; n = 94) thigh, and terminated at the deep system (45.3%; n = 96) and/or perforated the fascia (64.2%; n = 136), to join the superficial system. Giacomini vein morphology was not affected by the SSV termination anatomy and CEAP clinical class. Incompetence was detected less often (P < .001) in the Giacomini vein (4.7%; n = 10 of 212) than in the saphenous trunks cumulatively (53.3%; n = 113 of 212). Yet the odds ratio of Giacomini incompetence was 11.94 (7 of 33 over 3 of 169) in the presence of SSV reflux, and 11.67 (6 of 23 over 4 of 179) when both the great saphenous vein (proximal, proximal plus distal) and SSV were incompetent. CONCLUSION: Found in more than two thirds of limbs, the Giacomini vein has a complex anatomy that is linked vastly to the deep or superficial veins of the posteromedial thigh, but is unaffected by the anatomy of SSV termination and CEAP clinical class. Its presence proved insignificant to the extent, pattern, sites, and clinical severity of venous incompetence, yet the Giacomini vein was far less often susceptible to reflux than the saphenous trunks were. Routine Giacomini vein investigation is not justified in view of these findings. Investigation could be considered selectively in limbs with SSV incompetence, with or without great saphenous vein incompetence, supported by the high odds of concomitant Giacomini vein reflux.     

Segmental hypoplasia of the great saphenous vein and varicose disease.

OBJECTIVES: Primitive narrowing of great saphenous vein segments (saphenous hypoplasia) has been described in healthy limbs. The aim of the present study was to detect great saphenous vein segmental hypoplasia in limbs with varicose veins and to evaluate the local anatomical and haemodynamic patterns. MATERIALS AND METHODS: The incidence of saphenous hypoplasia and the local haemodynamic rearrangement were evaluated by duplex ultrasonography in 676 normal limbs and in 320 limbs with varicose veins. RESULTS: Segmental hypoplasia was demonstrated in 84 normal limbs and in 79 limbs with saphenous reflux. In the latter, the retrograde flow leaves the GSV at the proximal end of the hypoplastic segment to feed tributary veins. CONCLUSIONS: Saphenous hypoplasia occurs in varicose limbs more frequently than in healthy ones (p= >0.001). It greatly influences the path of the reflux and the anatomy of the varicose veins. GSV segmental hypoplasia can be detected preoperatively by duplex ultrasonography. Its occurrence may influence surgical management for two main reasons: in about 68% of varicose limbs with segmental hypoplasia, the distal GSV is competent. If the distal GSV is varicose, its size and flow direction is normalised by treating the accessory vein that bypasses the hypoplastic segment.     

Primary varicose veins: the sapheno-femoral junction, distribution of varicosities and patterns of incompetence.

OBJECTIVE: to determine the patterns of long saphenous vein (LSV) disease in primary varicose veins (VVs). DESIGN: a retrospective analysis of venous duplex scans performed on patients referred for treatment of primary VVs. METHODS: analysis was made of sapheno-femoral junction (SFJ) incompetence, non-SFJ incompetence, segmental and perforating vein incompetence, distribution of varicosities, deep venous insufficiency, and short saphenous incompetence. RESULTS: four hundred and eighty-one patients were assessed (median age 50 (range 12-98) years; male:female ratio 1:1.95), comprising 706 limbs. Forty-six per cent of limbs had a competent SFJ, 64% of which had no incompetent perforating vessels associated. Disease was more widespread when the SFJ was incompetent. Varicosities were most common in the calf, occurring at or below the level of incompetence within the LSV. Incompetent segments occurred most commonly above-knee. There was no obvious correlation between incompetent perforators and distribution of varicosities, or incompetent segments. Short saphenous incompetence and non-SFJ groin recurrence were associated more with a competent SFJ, the converse being true for the Giacomini vein. CONCLUSION: primary VVs develop in isolated segments of the superficial venous system (without connection to the deep system) at, or distal to, the underlying main trunk incompetence, suggesting a process of "spreading incompetence" from one focal point, producing varicosities (mainly in tributaries).     

Deep axial reflux, an important contributor to skin changes or ulcer in chronic venous disease

OBJECTIVE: We undertook this cross-sectional study to investigate the distribution of venous reflux and effect of axial reflux in superficial and deep veins and to determine the clinical value of quantifying peak reverse flow velocity and reflux time in limbs with chronic venous disease. PATIENTS AND METHODS: Four hundred one legs (127 with skin changes, 274 without skin changes) in 272 patients were examined with duplex ultrasound scanning, and peak reverse flow velocity and reflux time were measured. Both parameters were graded on a scale of 0 to 4. The sum of reverse flow scores was calculated from seven venous segments, three in superficial veins (great saphenous vein at saphenofemoral junction, great saphenous vein below knee, small saphenous vein) and four in deep veins (common femoral vein, femoral vein, deep femoral vein, popliteal vein). Axial reflux was defined as reflux in the great saphenous vein above and below the knee or in the femoral vein to the popliteal vein below the knee. Reflux parameters and presence or absence of axial reflux in superficial or deep veins were correlated with prevalence of skin changes or ulcer (CEAP class 4-6). RESULTS: The most common anatomic presentation was incompetence in all three systems (superficial, deep, perforator; 46%) or in superficial or perforator veins (28%). Isolated reflux in one system only was rare (15%; superficial, 28 legs; deep, 14 legs; perforator, 18 legs). Deep venous incompetence was present in 244 legs (61%). If common femoral vein reflux was excluded, prevalence of deep venous incompetence was 52%. The cause, according to findings at duplex ultrasound scanning, was primary in 302 legs (75%) and secondary in 99 legs (25%). Presence of axial deep venous reflux increased significantly with prevalence of skin changes or ulcer (C4-C6; odds ratio [OR], 2.7; 95% confidence interval [CI], 1.56-4.67). Of 110 extremities with incompetent popliteal vein, 81 legs had even femoral vein reflux, with significantly more skin changes or ulcer, compared with 29 legs with popliteal reflux alone (P =.025). Legs with skin changes or ulcer had significantly higher total peak reverse flow velocity (P =.006), but the difference for total reflux time did not reach significance (P =.084) compared with legs without skin changes. In contrast, presence of axial reflux in superficial veins did not increase prevalence of skin changes (OR, 0.73; 95% CI, 0.44-1.2). Incompetent perforator veins were observed as often in patients with no skin changes (C0-C3, 215 of 274, 78%) as in patients with skin changes (C4-C6, 106 of 127, 83%; P =.25). CONCLUSION: Continuous axial deep venous reflux is a major contributor to increased prevalence of skin changes or ulcer in patients with chronic venous disease compared with segmental deep venous reflux above or below the knee only. The total peak reverse flow velocity score is significantly higher in patients with skin changes or ulcer. It is questionable whether peak reverse flow velocity and reflux time can be used to quantify venous reflux; however, if they are used, peak reverse flow velocity seems to reflect venous malfunction more appropriately.     

Where does venous reflux start?

Purpose: This study was designed to identify the origin of lower limb primary venous reflux in asymptomatic young individuals and to compare patterns of reflux with age-matched subjects with prominent or clinically apparent varicose veins.Methods: Forty age- and sex-matched subjects with no symptoms (age, 15 to 35 years; 80 limbs; group A), 20 subjects (age, 19 to 32 years; 40 limbs) with prominent but nonvaricose veins (n = 26 limbs; group B), and 50 patients (age, 17 to 34 years; 100 limbs) with varicose veins (n = 64; group C) were examined with color flow duplex imaging. All proximal veins (above popliteal skin crease), superficial, perforator, and deep, in the lower limb were examined in the standing position, and all the distal veins in the sitting position. Patients who had a documented episode of superficial or deep vein thrombosis, previous venous surgery, or injection sclerotherapy were excluded from the study.Results: The prevalence of reflux in group A was 14% (11 of 80), in group B 77% (31 of 40), and in group C 87% (87 of 100). In more than 80% of limbs in the three groups, reflux was confined to the superficial veins alone. Deep venous reflux or combined patterns of reflux were uncommon even in group C. Reflux was detected in all segments of the saphenous veins and their tributaries. In the 125 limbs that had superficial venous incompetence, the below-knee segment of the greater saphenous vein was the most common site of reflux (85, 68%), followed by the above-knee segment of greater saphenous vein (69, 55%) and the saphenofemoral junction (41, 32%). Nonsaphenous reflux was rare (3, 2.4%). Reflux in the lesser saphenous vein (21, 17%) was seen in all groups, whereas involvement of both greater and lesser saphenous veins (8, 6.4%) was seen in group C alone. The incidence of multisegmental reflux was significantly higher in group C (61 of 64, 95%) than in group A (two of 11, 18%) or group B (14 of 26, 54%). The prevalence of distal reflux was comparable in all groups.Conclusions: Primary venous reflux can occur in any superficial or deep vein of the lower limbs. The below-knee veins are often involved in asymptomatic individuals and in those who have prominent or varicose veins. These data suggest that reflux appears to be a local or multifocal process in addition to or separate from a retrograde process. (J Vasc Surg 1997;26:736-42.)     

Patterns of saphenous reflux in women with primary varicose veins

OBJECTIVE: Varicose veins have been linked to great saphenous vein (GSV) reflux and in particular, with reflux at the saphenofemoral junction (SFJ). Early stages of disease, however, may be associated with limited, localized reflux in segments of the GSV and/or small saphenous vein (SSV). Ultrasound mapping of saphenous veins was performed to determine patterns of GSV and SSV reflux in women with simple, primary varicose veins. METHODS: Ultrasound mapping was performed prospectively in 590 extremities of 326 women with varicose veins (CEAP C 2 class) but without edema, skin changes, or ulcers (C 3 to C 6 ). Average age was 42 +/- 13 (SD) years (range, 8 to 87). Patterns of GSV and SSV reflux, obtained in the upright position, were classified as I: perijunctional, originating from the SFJ or saphenopopliteal junction (SPJ) tributaries into the GSV or SSV; II: proximal, from the SFJ or SPJ to a tributary or perforating vein above the level of the malleoli; III: distal, from a tributary or perforating vein to the paramalleolar GSV or SSV; IV: segmental, from a tributary or perforating vein to another tributary or perforating vein above the malleoli; V; multisegmental, if two or more distinct refluxing segments were detected; and VI: diffused, involving the entire GSV or SSV from the SFJ or SPJ to the malleoli. RESULTS: Reflux was detected in 472 extremities (80%): 100 (17%) had reflux in both the GSV and SSV, 353 (60%) had GSV reflux only, and 19 (3%) had SSV reflux only, for a total prevalence of 77% at the GSV and 20% at the SSV. The most common pattern of GSV reflux was segmental (types IV and V) in 342 (58%) of 590; either one segment in 213 (36%) or more than one segment with competent SFJ in 99 (17%), or incompetent SFJ in 30 (5%), followed by distal GSV reflux (type III) in 65 (11%), proximal GSV reflux (type II) in 32 (5%), diffused throughout the entire GSV (type VI) in 10 (2%), and perijunctional (type I) in 4 (<1%). GSV refluxing segments were noted in the SFJ in 72 (12%) and in the thigh in 220 (37%), and leg (or both) in 345 (58%). CONCLUSIONS: The high prevalence of reflux justifies ultrasound mapping of the saphenous veins in women with primary varicose veins. Correction of SFJ reflux, however, may be needed in 相似文献