Prevalence of deep venous reflux in patients with primary superficial vein incompetence

PURPOSE: This prospective study was designed to determine the prevalence of deep reflux and the conditions under which it may occur in patients with primary superficial venous reflux and absence of deep venous thrombosis (DVT). METHODS: We studied 152 limbs in 120 consecutive patients in the standing position who had superficial venous reflux with color flow duplex scanning. Limbs with documented evidence of DVT or post-thrombotic vein wall changes during the examination were studied but not included in the analysis. Limbs were divided into those that had at least reflux in the saphenofemoral, the saphenopopliteal, or the gastropopliteal junction and into those with nonjunctional reflux in the superficial and gastrocnemial veins. Peak velocity and duration of reflux were measured. To examine the recirculation theory, we tested the deep veins by occluding and refluxing saphenous veins 10 cm below the sampling site. RESULTS: Thirteen limbs in 11 patients (9%) were excluded because of previous DVT. Of the remaining 139 limbs, 106 (76%) had junctional reflux. Saphenofemoral junction was involved in 89 limbs (84%), saphenopopliteal junction in 18 (17%), and gastropopliteal junction in 7 (4%). In 33 limbs (24%), reflux was detected in the main trunk or tributaries of the saphenous veins alone with no junctional incompetence. Femoral or popliteal reflux was present in 31 limbs (22%). This reflux was segmental in 27 limbs, and it was limited in the junction in 24 limbs. The mean duration of deep venous reflux was 0.9 seconds, it ranged from 0.6 to 3.7 seconds, and it was significantly shorter than that in the superficial veins (2.6 seconds; P <.0001). In the absence of junctional reflux, the prevalence of deep venous insufficiency (DVI) was significantly lower compared with that in limbs with junctional involvement (2 of 33 vs 29 of 106; P =.038). The mean duration of deep venous reflux in these groups was comparable (0.85 seconds vs 0. 91 seconds; P =.44). Occlusion of the incompetent superficial veins reduced somewhat the duration of the deep venous reflux but did not abolish it (0.88 seconds vs 0.82 seconds; P =.072). The presence of DVI was associated with junctional reflux of high peak velocity and long duration. CONCLUSIONS: The prevalence of DVI in patients with primary superficial venous reflux and without history of DVT is 22%. However, this reflux is segmental, mainly in the common femoral vein, and is of short duration. It is associated with the presence of junctional incompetence that has a high peak velocity and long duration. These findings may explain why surgical correction of superficial reflux abolishes DVI.     

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.     

Anatomic and physiologic characteristics of venous ulceration

Purpose: The purpose of this study was to describe the combination of physiologic and anatomic changes present in limbs with venous ulceration.Methods: Limbs with venous ulceration (chronic venous insufficiency [CVI] class 3) were assessed prospectively by air plethysmography and color-flow duplex scanning. Findings were compared with clinically normal contralateral limbs and normal control limbs (CVI class 0), as well as with limbs without skin changes (CVI class 1).Results: Of the 120 ulcerated limbs studied, only 28% had deep system incompetence. Reflux at the saphenofemoral or saphenopopliteal junctions without perforator incompetence was present in 40%. Raised venous filling indexes (>2 ml/s) and high residual volume fractions (>20%) were present in 90% and 95%, respectively. Although levels of these parameters were significantly different from the other groups (p < 0.05), absolute ejection volumes and outflow parameters were the same (p > 0.05). One third of contralateral "normal" limbs (class 0) had abnormal duplex scanning findings. The ratio of venous filling time to residual volume fraction produced a useful discriminating index for the ulcerated limb.Conclusion: The ulcerated limb was characterized by high rates of reflux and high residual volumes that were independent of the site of reflux. This study highlights the important association of venous ulceration and isolated superficial venous system incompetence. (J VASC SURG 1994;20:759-64.)     

Development of reflux in the perforator veins in limbs with primary venous disease

OBJECTIVE: To determine the patterns by which perforator vein (PV) reflux develops in patients with primary chronic venous disease (CVD). METHODS: Patients with CVD who had at least two examinations with duplex ultrasonography before any treatment were included in this study. These were patients who were offered an operation at their first visit, but for various reasons treatment was postponed. All affected limbs were classified by the CEAP classification system. A detailed map of normal and refluxing sites was drawn on an anatomic chart by using several landmarks of the skin, muscle, and bone. Reflux was induced by distal limb compression followed by sudden release by using rapid-inflation pneumatic cuffs and dorsiplantar flexion. All new reflux sites were documented. The PV reflux was divided into ascending type, descending type (re-entry flow), and those that developed in new locations, which did not have reflux in any system at that level. RESULTS: The total number of patients studied was 127 (158 limbs). There were 29 limbs (18%) in 26 patients with reflux development in the PV. In total, 38 new incompetent PVs were identified. The median time for the examination was 25 months (range, 9-52 months). Reflux in a previously normal PV at a re-entry site was detected in 15, in an ascending manner from an extension of superficial vein reflux in 18, and in a new, previously intact location in 5. At the new sites, reflux in the superficial veins connected to the incompetent PVs was always present. PVs connected to the great saphenous vein system were most common (n = 27), followed by those connected to short saphenous (n = 8) and nonsaphenous (n = 3) veins. Worsening in the clinical class was observed in 11 limbs: 5 from class 2 to 3, 2 from class 2 to 4, 2 from class 3 to 4, and 2 from class 4 to 6. The worsening could not be attributed to the PV reflux alone, because other veins became incompetent as well. CONCLUSIONS: Reflux in PVs develops in ascending fashion through the superficial veins, at re-entry points, and at new sites. Worsening of CVD is observed with new PV reflux, but many other factors play a major role, and therefore a causative association is difficult to prove.     

Current concepts in chronic venous ulceration.

OBJECTIVES: despite numerous reports on the distribution of reflux in patients with venous ulceration, there is no consensus on the contribution of each venous system. This study was performed to evaluate the distribution of reflux in this group of patients. METHODS: a literature search from 1980 to 1998 was performed. Because duplex scanning is the best method for detecting venous reflux, we only included reports that used this diagnostic modality. All studies with less than 30 ulcerated limbs were excluded. Since most reports did not give detailed data on perforator veins, reflux in these veins was combined with the superficial and deep veins. Documented episodes of superficial or deep vein thrombosis were noted. RESULTS: thirteen studies that included 1249 ulcerated limbs fulfilled the inclusion criteria. The mean age of patients was 59 years (95% CI: 54-63, range: 14-93). Reflux was detected in 1153 (92%) of limbs. Reflux confined to the superficial veins alone was seen in 45% of limbs, in the deep veins alone in 12% and in both the superficial and deep veins in 43% of limbs. The overall involvement of the superficial veins was 88% and of the deep veins 56% (p <0. 0001). A documented episode of deep vein thrombosis was reported in only six of the 13 studies and the incidence was found to be 32%. CONCLUSIONS: reflux in the superficial veins is seen in 88% of limbs with venous ulcers (CEAP classes 5 and 6). Isolated superficial vein incompetence is detected in 45%, while reflux in the deep venous system alone is seen in only 12%. These data have significant clinical implications, since reflux in the superficial system can be easily eliminated by excision of the affected veins.     

Prevalence of varicose veins and venous anatomy in patients without truncal saphenous reflux.

OBJECTIVES: To determine the prevalence and distribution of primary venous reflux in the lower limbs in patients without truncal saphenous reflux. DESIGN: Prospective cohort study. PATIENTS AND METHODS: One thousand and seven hundred and twelve patients with suspected venous disease were examined by duplex ultrasonography. Seven hundred and thirty-five patients had primary varicose veins with competent saphenous trunks. Limbs with truncal saphenous reflux, deep vein reflux or obstruction, previous injection sclerotherapy or vein surgery, arterial disease and inflammation of non-venous origin were excluded from further consideration. The CEAP classification system was used for clinical staging. Systematic duplex ultrasound examination was undertaken to assess the distribution of incompetent saphenous tributaries. RESULTS: The prevalence of primary reflux with competent saphenous trunks was 43%. Reflux of GSV calf tributaries was the most common. The majority of the limbs (96%) belonged to chronic venous disease classes C1 and C2 of the CEAP classification. CONCLUSIONS: Superficial venous reflux causing varicose veins in the presence competent saphenous trunks is very prevalent in this series in contrast to other studies, presumably reflecting differing patient populations. Our data clearly show that varicose veins may occur in any vein and do not depend on truncal saphenous incompetence. Careful duplex ultrasound evaluation allows the pattern of venous reflux to be established in this group of patient ensuring appropriate management of varices.     

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.     

Evaluation of non-invasive and invasive methods in the assessment of short saphenous vein termination

Surgery of the short saphenous vein is associated with a high recurrence rate because of variations in the anatomy or inadequate clinical examination. To prevent this, accurate definition of the pattern and level of termination of the saphenopopliteal junction and flush ligation is necessary. Clinical examination, Doppler ultrasound, duplex scanning and peroperative venography have been compared to assess the level of termination of the short saphenous vein. In all, 64 limbs of 46 patients were examined. In 39 limbs there was primary short saphenous incompetence, in 13 limbs there was recurrent short saphenous incompetence; in ten of these there was incompetence of the gastrocnemius vein. In 12 limbs a duplex scan did not demonstrate incompetence of the short saphenous vein or gastrocnemius vein. The accuracy of these methods when locating incompetence of the short saphenous vein to within 2 cm of the saphenopopliteal junction was 56 per cent for clinical examination, 64 per cent for Doppler ultrasound and 96 per cent for duplex scanning. When there was no saphenopopliteal junction (9 per cent), duplex scanning correctly detected the pattern of the incompetent vein. The apparent success of clinical examination was because the vein was not felt above the femoral intercondylar groove and 52 per cent of the veins terminated at this level. Duplex scanning is a non-invasive technique which is almost as accurate as venography and provides additional haemodynamic information about the incompetent veins by demonstrating the presence and extent of reflux.     

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.     

Haemodynamic and clinical impact of superficial, deep and perforator vein incompetence.

OBJECTIVE: The purpose of this study was to assess the effect of venous incompetence of the deep, superficial and perforator veins combined (i.e. multi-system incompetence) on the venous haemodynamics and clinical condition of limbs with chronic venous disease (CVD). METHODS: One hundred and thirty two limbs (16-C(1); 30-C(2); 20-C(3); 25-C(4); 21-C(5); 20-C(6)) of 121 patients were studied. We excluded those with previous venous surgery/sclerotherapy, peripheral arterial disease, recent deep vein thrombosis (< or =6 months), or inability to comply with the tests. The CEAP clinical class was assessed. Duplex ultrasonography (ultrasound) enabled classification according to: the presence of superficial([S]) (+/- perforator([P])) or deep([D]) (+/-S, +/-P) reflux (>.5s); the number of incompetent venous systems (single-system([S/P/D]), dual-system([S+P/S+D/P+D]), or triple-system([S+P+D])), and the number of incompetent perforators([0/1/2/> or =3]). The amount of reflux (Venous Filling Index([VFI])); calf pump Ejection Fraction([EF]), and Residual Volume Fraction([RVF]) were studied with air-plethysmography. RESULTS: VFI in limbs with triple-system incompetence (VFI median 6.68 [IQR: 4.7-9.7]ml/s) was higher than in limbs with dual-system incompetence (4.5 [2.1-7.4]ml/s), and VFI in the latter was higher than in limbs with single-system incompetence (1.3 [0.69-2.3]ml/s)(p<0.01 Kruskal-Wallis). Although EF changes were small, RVF in limbs with triple-incompetence (39 [30-51] %) was higher than in single-system incompetence (26 [16-33] %)(p<0.01 Mann-Whitney). Limbs with superficial (+/-P) incompetence had a lower VFI (p<0.01) and RVF (p<0.02) than limbs with deep (+/-S+/-P) incompetence, and limbs with > or =2 incompetent perforator veins had a higher VFI (p<0.04) than those without perforators. All limbs with single-system incompetence were C(1-3,) whereas 78% of those with triple-incompetence were C(4-6) (p<0.01). The number of incompetent systems increased with clinical class (p<0.01). CONCLUSIONS: The frequency of incompetence of more than one venous system increased with the clinical severity of venous disease and was accompanied by a 5-fold increase in the amount of reflux and a 50% rise in the RVF. The number of incompetent perforators per limb increased with the amount of reflux. The number of incompetent venous systems (superficial, deep, perforator) and perforator veins can be assessed by duplex ultrasound giving an objective indication of the functional severity of venous disease. In this way duplex ultrasound could be used to grade venous function in clinical practice as an alternative to APG measures which are less widely available.     

Perforator vein incompetence in chronic venous disease: a multivariate regression analysis model

OBJECTIVES: In the presence of superficial and deep vein insufficiency the effects, if any, of concurrent incompetent perforator veins (IPVs) on clinical status are masked. On the basis of multivariate regression analysis, this study examines the significance of perforator vein incompetence across the clinical classes of CEAP (C-class CEAP ) in relation to the superficial and deep systems, and assesses the role of factors implicated in the presence and number of IPVs in chronic venous disease (CVD). METHODS: The study included 525 limbs in 360 patients, ages 17 to 96 years, referred for investigation of CVD. The protocol entailed history taking, physical examination, and duplex scanning (reflux > 0.5 s), with emphasis on IPVs. Exclusion criteria included peripheral vascular disease, unrelated edema, severe chronic obstructive pulmonary disease, and recent (< 1 year) deep vein thrombosis (DVT). RESULTS: Limbs were stratified as C 0 , 84; C 1 , 25; C 2 , 231; C 3 , 66; C 4 , 48; C 5 , 23; and C 6 , 48. C-class CEAP was separately regressed with age ( P < .001), sex ( P < .25), contralateral CVD ( P < .2), CVD recurrence ( P = .022), previous DVT ( P < .001), superficial vein reflux ( P < .001); deep vein reflux ( P < .001), perforator vein reflux ( P < .001), and number of IPVs ( P < .001). In an optimized multivariate regression analysis of C class CEAP with all significant variables combined, age ( P < .001), previous DVT ( P = .017), superficial vein reflux ( P < .001), deep vein reflux ( P < .001), and number of IPVs ( P = .008) emerged as predictors of CVD severity (CEAP), based on the equation C class CEAP = -0.2807 + 0.028013 Age + 0.58530 Previous DVT + 0.3450 Superficial vein reflux + 0.17781 Deep Reflux + 0.14537 IPVs ( R 2 = 37.4%; P < .001).Perforator incompetence was predicted by superficial vein reflux ( P < .001) and deep vein reflux ( P = .044), age ( P = .019), CVD recurrence ( P = .038), and sex ( P = .018), as follows: Perforator incompetence = -0.2532 + 0.006457 Age + 0.41366 Superficial reflux + 0.06766 Deep reflux + 0.2450 CVD recurrence - 0.21310 Sex ( R 2 = 33.3%; P < .001). Number of IPVs per limb was best associated with superficial reflux ( P < .001) and deep reflux ( P = .023), linked as IPVs = - 0.11789 + 0.41323 Superficial reflux + 0.07646 Deep reflux ( R 2 = 26.1%; P < .001). CONCLUSION: Perforator incompetence proved to be a significant factor for determination of CVD severity according to C-class CEAP , withstanding the conspicuous confounding effects of the superficial and deep venous systems. Perforator incompetence was significantly linked to aging, superficial or deep vein incompetence, recurrence of superficial disease, and sex, whereas the IPV number, regardless of location, depended on the presence of superficial or deep venous reflux.     

Duplex ultrasound mapping of sites of deep to superficial incompetence in primary varicose veins.

Most patients undergoing treatment for primary varicose veins have only a clinical assessment or examination with a continuous wave Doppler. In this study duplex ultrasound was used to determine the site of deep to superficial reflux in 137 limbs of 96 patients presenting with primary varicose veins. The incidence of saphenopopliteal (22%) and perforator (28%) incompetence was higher than that in previous studies based on clinical examination. Only five limbs had deep venous incompetence at the popliteal level and three of these limbs had lipodermatosclerosis or ulceration. The saphenopopliteal junction was either absent or more than 10 cm from the knee joint in 13% of limbs. The information obtained from duplex scanning of patients with primary varicose veins facilitates surgical management and may lead to a lower recurrence rate.     

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.)     

DUPLEX ULTRASOUND MAPPING OF SITES OF DEEP TO SUPERFICIAL INCOMPETENCE IN PRIMARY VARICOSE VEINS

Most patients undergoing treatment for primary varicose veins have only a clinical assessment or examination with a continuous wave Doppler. In this study duplex ultrasound was used to determine the site of deep to superficial reflux in 137 limbs of 96 patients presenting with primary varicose veins. The incidence of saphenopopliteal (22%) and perforator (28%) incompetence was higher than that in previous studies based on clinical examination. Only five limbs had deep venous incompetence at the popliteal level and three of these limbs had lipodermatosclerosis or ulceration. The saphenopopliteal junction was either absent or more than lOcm from the knee joint in 13% of limbs. The information obtained from duplex scanning of patients with primary varicose veins facilitates surgical management and may lead to a lower recurrence rate.     

Definition of venous reflux in lower-extremity veins

PURPOSE: This prospective study was designed to determine the upper limits of normal for duration and maximum velocity of retrograde flow (RF) in lower extremity veins. METHODS: Eighty limbs in 40 healthy subjects and 60 limbs in 45 patients with chronic venous disease were examined with duplex scanning in the standing and supine positions. Each limb was assessed for reflux at 16 venous sites, including the common femoral, deep femoral, and proximal and distal femoral veins; proximal and distal popliteal veins; gastrocnemial vein; anterior and posterior tibial veins; peroneal vein; greater saphenous vein, at the saphenofemoral junction, thigh, upper calf, and lower calf; and lesser saphenous vein, at the saphenopopliteal junction and mid-calf. Perforator veins along the course of these veins were also assessed. In the healthy volunteers, 1553 vein segments were assessed, including 480 superficial vein segments, 800 deep vein segments, and 273 perforator vein segments; and in the patients, 1272 vein segments were assessed, including 360 superficial vein segments, 600 deep vein segments, and 312 perforator vein segments. Detection and measurement of reflux were performed at duplex scanning. Standard pneumatic cuff compression pressure was used to elicit reflux. Duration of RF and peak vein velocity were measured immediately after release of compression. RESULTS: Duration of RF in the superficial veins ranged from 0 to 2400 ms (mean, 210 ms), and was less than 500 ms in 96.7% of these veins. In the perforator veins, regardless of location, outward flow ranged from 0 to 760 ms (mean, 170 ms), and was less than 350 ms in 97% of these veins. In the deep veins, RF ranged from 0 to 2600 ms. Mean RF in the deep femoral veins and calf veins was 190 ms, and was less than 500 ms in 97.6% of these veins. In the femoropopliteal veins, mean RF was 390 ms, and ranged from 510 to 2600 ms in 21 of 400 segments; however, RF was less than 990 ms in 99% of these veins. Duration of RF was significantly longer in all three veins systems in patients (P <.0001 for all comparisons). With a cutoff value of more than 1000 ms rather than more than 500 ms, prevalence of abnormal RF in the femoropopliteal veins was significantly reduced, from 29% to 18% (P =.002). Thirty-seven vein segments (2.4%) had RF greater than 500 ms in the supine position, compared with less than 500 ms in 22 of these vein segments (59%) in the standing position. Of the 48 vein segments (3.1%) with RF greater than 500 ms in the standing position, RF was less than 500 ms in 6 of these vein segments (13%) in the supine position. Similar observations were noted in patient veins. There was no association between RF and peak vein velocity. Peak vein velocity had no significance in determining reflux. CONCLUSIONS: The cutoff value for reflux in the superficial and deep calf veins is greater than 500 ms. However, the reflux cutoff value for the femoropopliteal veins should be greater than 1000 ms. Outward flow in the perforating veins should be considered abnormal at greater than 350 ms. Reflux testing should be performed with the patient standing.     

Primary deep venous incompetence in limbs with varicose veins

Deep venous valvular incompetence (DVI) of primary, non-thrombotic origin has received little interest compared with secondary, postthrombotic DVI. In this study both limbs of 308 patients with untreated or surgically treated varicose veins in at least one limb were examined with Doppler ultrasound for signs of deep vein reflux. Ascending venography was used to exclude limbs with secondary DVI and descending venography to assess valve function. Doppler examination disclosed reflux in 3.5% of the "normal" limbs but in none of the limbs without recurrent varicose veins. A high incidence of primary DVI was found in limbs with untreated varicose veins (20.6%, p less than 0.001) and in those with recurrent or residual varicose veins (42.9%, p less than 0.001), compared with that in "normal" limbs. Popliteal vein reflux was observed in 14% and 37% in these two groups and a combination of femoral and popliteal reflux in 4% and 16%. Reflux of grade 2 or more at descending venography was noted in 43 of 78 limbs with Doppler evidence of reflux. Primary DVI is a common condition in patients with varicose veins. Further studies are needed to determine its clinical significance.     

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.     

Influence of phlebographic abnormalities on the natural history of venous ulceration

Eighty-five limbs in 73 patients with a healed venous ulcer were assessed by ascending and descending phlebography, foot volume plethysmography and transcutaneous oxygen measurements. Forty-four limbs had post-thrombotic changes on ascending phlebography. In 24 (28 per cent) these extended into the femoral vein, while in 20 (24 per cent) only the calf veins were involved. In the 41 limbs (48 per cent) with normal deep veins on ascending phlebography, 11 had evidence of localized incompetence of the calf communicating veins, 14 had either long saphenous incompetence, deep vein reflux to the level of the knee or below, or both of these abnormalities, and 16 limbs had no phlebographic abnormalities. However all limbs had a decreased half volume refilling time on foot volume plethysmography. Limbs with post-thrombotic changes extending into the femoral vein were associated with a significantly longer history of ulceration and more ulcer recurrences than limbs with calf vein damage (P less than 0.05 for each) and limbs with normal deep veins (P less than 0.01 for each). However, these limbs did not have lower transcutaneous oxygen ratios or longer times to achieve ulcer healing. Ascending phlebography identified a group of limbs with extensive post-thrombotic changes in which there was a higher incidence of ulcer breakdown, but this was not associated with a delay in ulcer healing.     

New insights into perforator vein incompetence.

BACKGROUND: there has been much controversy on the role of perforator veins in the development of chronic venous disease (CVD). This study was designed to determine the duration and direction of flow of lower limb perforator veins (PVs) in relation to their location, diameter and competency status of superficial and deep veins, in healthy volunteers and patients with different grades of CVD. PATIENTS AND METHODS: thirty limbs in 15 symptom-free volunteers and 103 limbs in 75 patients with signs and symptoms of CVD were examined with colour-flow duplex scanning. Superficial, perforator and deep veins were studied in the standing and sitting positions. Flow-velocity characteristics, the number and maximum PV diameter at the deep fascia and subfascially were determined. A PV was considered incompetent when the outward flow lasted >0.5 s. RESULTS: 581 PVs were found in the patients and 106 in the volunteers. 163 PVs (28%) were incompetent in the first group and none in the latter. The total number of PVs and the number of incompetent PVs per limb increased significantly with the severity of CVD. The mid-calf area had more competent and incompetent PVs in patients (p <0.01). Mean diameter of incompetent PVs in all the CVD classes was significantly larger than that of competent PVs. Competent PVs tended to be larger with increasing severity of CVD and they were significantly larger in the CVD classes 4 to 6 compared to controls (p <0.01). Subfascial PV diameter was markedly larger than that at the fascial level (p <0.001) regardless of the CVD class. A subfascial PV diameter of >3.9 mm (95% CI 3.4 to 4.4 mm) indicated incompetence. However, the reverse was not true, because about a third of incompetent PVs had a subfascial diameter of <3.9 mm. Both competent and incompetent PVs were smaller when located at the lower thigh, knee, ankle and anterior aspect of the calf than those found in the rest of the calf and mid-thigh (p =0. 03). Both inward and outward flow was found more often in patients than in controls (70/418 vs. 9/106, p =0.048). Most incompetent PVs had outward flow alone (126, 77%). PV incompetence was most frequently associated with reflux in superficial veins (120, 74% (p <0.0001), followed by reflux in both the superficial and deep veins (34, 21%) and reflux in the deep veins alone (9, 5%). The mean duration of outward flow was markedly longer in the presence of both superficial and deep vein reflux compared to superficial (p <0.001) or deep vein reflux alone (p <0.0001). CONCLUSIONS: the number of incompetent PVs and the diameter of both competent and incompetent PV increases with the severity of CVD. Bidirectional PV flow is more common in patients than in normal volunteers, while 77% of the incompetent PVs have outward flow alone. PV incompetence is most often associated with reflux in the superficial veins, indicating that deep venous reflux is rarely the primary cause of PV insufficiency.     

Patterns and distribution of isolated calf deep vein thrombosis.

PURPOSE: In the search for calf deep vein thrombosis (DVT) with color-flow duplex scanning (CFDS), most vascular laboratories investigate only the posterior tibial and peroneal veins. Few laboratories assess the soleal and gastrocnemial veins. This study was designed to determine the patterns and distribution of isolated calf DVT, including the soleal and gastrocnemial veins. METHODS: In the last 3 years, 5250 patients (mean age, 66 +/- 15 years; range, 22 to 93 years) were referred to the vascular laboratory for clinical suspicion of DVT and underwent examination with CFDS. All superficial and deep named veins, excluding the anterior tibial from groin to ankle, were imaged. Of the deep veins in the calf, the peroneal, the posterior tibial, the gastrocnemial, and the soleal veins were examined throughout their length. RESULTS: DVT was detected in 14% of the patients. Isolated calf DVT was detected in 282 limbs of 251 patients (4.8%). No significant difference was noted for the sex (114 men vs 137 women; P =.15) or the limb preference (145 left vs 137 right; P =.5). The peroneal veins were most frequently involved, with 115 limbs (41%) affected. The soleal veins were involved in 109 limbs (39%), followed by the posterior tibial in 105 limbs (37%) and the gastrocnemial in 79 limbs (29%). Thrombus in the soleal vein alone was found in 57 limbs (20%), in the gastrocnemial in 48 limbs (17%), in the peroneal in 41 limbs (15%), and in the posterior tibial vein in 35 limbs (12%). Thrombus confined to a single or paired vein was found in 181 limbs (64%). Thrombus involving two different veins (27%) was the second most frequent pattern, and thrombus in three (7%) or four (1.4%) different veins was less prevalent. Isolated thrombosis in veins not routinely investigated was found in 113 limbs (40%; soleal, n = 57; gastrocnemial, n = 48; soleal + gastrocnemial, n = 8). Multifocal origin of thrombosis, defined as thrombi in two different veins that do not anatomically communicate, was identified in 63 limbs (22%). CONCLUSION: Forty percent of the patients with acute isolated calf DVT would be judged to have normal CFDS examination results if the muscular veins in the calf were not imaged. Multifocal origin of thrombosis was found in 22% of the involved limbs. The prevalence of thrombosis in any calf vein either alone or in combination is comparable. Accordingly, the soleal and gastrocnemial veins should be examined routinely.