Original. The theory of primary varicose veins developing in a VENOUS REFLUX PATTERNS IN PRIMARY VARICOSE VEINS: ULTRASOUND FINDINGS ABSTRACT

Transcription

1 pp11-16 Original A R T I C L E VENOUS REFLUX PATTERNS IN PRIMARY VARICOSE VEINS: ULTRASOUND FINDINGS JASON PAIGE 1, G HEATHER CLARKE 2, MICHAEL J GRIGG 3, PETER A BLOMBERY 4 AND GEORGE M SOMJEN 5 1.Jason Paige BSc DMU (Vasc) Vascular Sonographer, Vascular Investigations, Mornington Vascular Imaging Services, Box Hill 2. G Heather Clarke BS MS PhD Senior Lecturer Department of Medical Radiations, RMIT University 3.Michael J Grigg MBBS FRACS Professor of Surgery, Monash University 4. Peter A Blombery MBBS, PhD, FRACP DDU Vascular Physician, Heart Centre,Alfred Hospital, Prahran 5. George M Somjen MS, FRCS(Ed), FRACS, DDU Vascular Surgeon, Peninsula Health, Frankston Hospital, Vascular Investigations, Mornington Institution: Department of Medical Radiations RMIT University, Bundoora, Victoria, Australia Introduction The theory of primary varicose veins developing in a descending manner by reflux through junctional valves (i.e. saphenofemoral and saphenopopliteal incompetence) dominated the literature through most of the nineteenth and twentieth centuries 1-3. There were also staunch supporters of the ascending theory of reflux originating distally through incompetent calf perforating veins 4. Recent studies have shown primary varicose veins to be much more complex than previously thought. Duplex ultrasound has been used to demonstrate that a transfascial escape from the deep veins to the superficial veins is not a precondition for varicose veins to develop 5-9. Thibault 7 demonstrated this pattern to be common in a group with cosmetic or minor varicose veins. Varicose veins arising from the pelvis are another source of non junctional reflux, with a variety of communications between leg varicosities and the deep veins of the pelvis having been demonstrated using venography ABSTRACT Objective The objective of the study was to determine the patterns of superficial reflux and deep venous incompetence associated with surgically significant varicose veins. In the absence of junctional incompetence an attempt was made to categorise the superficial reflux patterns. A pelvic source of reflux was also investigated in a selected number of patients. Methods The results of 592 duplex ultrasound examinations performed for assessment of primary varicose veins were reviewed.the pattern and source of reflux were identified in each limb and the prevalence of these patterns determined. Results The majority of limbs (68.1%) had transfascial (communication with the deep veins of the leg) reflux. No evidence of communication with the deep veins of the leg was shown in 31.9% of limbs. Four patterns of non transfascial reflux were identified : proximal (12.0%), medial (5.9%), posterior (3.0%) and isolated (8.1%), based on the distribution of the varices in the leg. Ovarian vein incompetence was common in the proximal, medial and posterior groups. Deep venous incompetence was found in 334 limbs, the majority of which occurred proximal to junctional reflux. Conclusion Primary varicose veins result from a dynamic interaction between the deep, superficial and pelvic veins.the reflux patterns are often complex or unique.these finding are not in line with the traditional simplistic concepts on the aetiology of varicose veins. Keywords Varicose veins, duplex ultrasound, reflux, pelvic veins. Communication between leg varicosities and the veins draining the pubic region have been demonstrated using duplex ultrasound 13 however a link between this pattern and the internal veins of the pelvis has not been established. Address Correspondence to: Jason Paige, Vascular Investigations, The Bays Hospital, Mornington, Victoria 3931Australia. Phone: Fax: jpaige@iprimus.com.au A USTRALIAN & NEW Z EALAND J OURNAL OF P HLEBOLOGY V OLUME 7(2):DECEMBER

2 J Paige, G Heather Clarke, M J Grigg, P A Blombery and GM Somjen The delineation of primary varicose veins is further complicated by the occurrence of incompetence in the deep veins often associated with varicose veins 14,15. The occurrence and frequency of this presentation and its role in the aetiology of primary varicose veins has been debated with some believing that primary incompetence of the deep veins is the cause of superficial incompetence 16. Others have shown surgical correction of superficial incompetence to abolish primary deep venous incompetence 17,18, suggesting that reflux in the deep veins occurs secondary to superficial incompetence 19, or simultaneously together. The correct identification of these various patterns of reflux is important to plan appropriate treatment. The prevalence of junctional and perforator incompetence in primary varicose veins is relatively well defined in the literature however the patterns and prevalence of varicosities in the absence of junctional or perforator incompetence and the patterns and prevalence of deep venous incompetence in association with primary varicose veins have not been determined. The aim of this study was to determine the patterns of superficial reflux and deep venous incompetence associated with surgically significant varicose veins. An attempt was made to categorise the superficial reflux patterns in the absence of junctional incompetence. A pelvic source of reflux was also investigated in a selected number of patients. Methods The results of venous duplex ultrasound examinations, conducted during a two year period ( ), of 592 limbs in 422 patients were reviewed. All patients had primary varicose veins of surgical significance with a clinical CEAP classification of 2 or greater. Patients with a history of deep venous thrombosis or duplex evidence of previous deep venous thrombosis were excluded from the study. Colour duplex ultrasound examinations were performed using a GE Logiq 700 or a Toshiba 6000 ultrasound machine, using linear array probes with imaging frequencies in the range of 8 to 13 MHz. Patients were scanned standing, with the limb being examined, non weight bearing. A routine scan consisted of examination of the long saphenous vein, short saphenous vein, and the deep veins including the femoral, popliteal and calf veins. The thigh and calf were examined for perforators. Significant reflux was defined as reflux persisting for greater than 0.5 seconds 23. Careful assessment was made in each case to determine the presence or absence of transfascial reflux (from the deep to the superficial veins in the leg, i.e. saphenofemoral, saphenopopliteal or perforator incompetence). If no transfascial communication in the leg was identified then the varices were traced to the most proximal discernable source and were categorized as proximal if they were traced to the tributaries which drain the superficial pubic area and the abdominal wall, medial if the varices were traced to the vulva or perineal region, or posterior if the varices were traced to the gluteal muscles or peri-rectal region. Those varices which could not be placed in one of these three categories were called isolated varices. Thus four categories for those varicosities with no transfascial communication in the leg were determined : proximal, medial, posterior or isolated. If varices were traced to the proximal tributaries then an attempt was made to determine which tributary communicated with the refluxing veins, i.e. the superficial external pudendal vein, superficial inferior epigastric vein, or superficial circumflex iliac vein. These proximal tributaries are illustrated in Figure 1. Patients suspected of having varicose veins arising from a pelvic source (with or without transfascial reflux) underwent trans-abdominal scanning of their pelvic veins including both ovarian and both internal iliac veins. Scanning was performed with the patient in a semi-recumbent position on an examination couch or on a tilt table at an angle of 30 degrees reverse Trendelenburg. The ovarian and internal iliac veins were scanned using the technique described by Richardson 24. The results were collated and entered into a database (Microsoft Access) detailing all sites of reflux and in particular the sources of reflux in the long saphenous vein. The prevalence of each pattern of incompetence was determined. Differences in the age, sex and clinical presentation of transfascial and non-transfascial patterns of reflux were assessed using Student s t-test. Results Of the 422 patients (592 limbs), 324 patients (465 limbs) were female and 98 patients (127 limbs) were male. Seventy three limbs (12.6%) in 52 patients had clinical evidence of skin changes and or ulceration (Clinical CEAP classification of 4, 5 or 6 25 ). The mean patient age was 54 years (range years). The average age of those patients with no evidence of transfascial escape was significantly lower than the average age of those with a transfascial escape (Students t-test p=0.03). There was a significantly higher proportion of females (p=0.03) and a lower proportion of limbs with skin changes or ulceration (p=0.003) in the group with no evidence of transfascial escape when compared to the group with transfascial reflux (Table 1). Varicose veins with evidence of transfascial reflux A transfascial escape point was seen in 403 of 592 limbs (68.1%) in 287 patients. Two hundred patients (289 limbs) were female and 87 patients (114 limbs) were male. One type of communication with the deep veins (saphenofemoral, saphenopopliteal, thigh perforator or calf perforator) occurred in 264 limbs and 139 limbs had two or more types of commu- 12 V OLUME 7(2):DECEMBER 2003 AUSTRALIAN & NEW Z EALAND J OURNAL OF P HLEBOLOGY

3 Venous reflux patterns in primary varicose veins: ultrasound findings nication with the deep veins. Saphenofemoral incompetence was the most common source of reflux (47.0%), followed respectively by calf perforator incompetence (29.1%), saphenopopliteal incompetence (11.7%) and thigh perforator incompetence (4.1%). Calf perforator incompetence occurred in conjunction with junctional reflux in 134 limbs and in conjunction with tributaries arising from the pelvis or abdominal wall in 38 limbs. There were 17 limbs with calf perforator incompetence as the sole source of reflux. Data for patterns with multiple sources of reflux are shown in Figure 2. Varicose veins with no evidence of transfascial reflux There was no evidence of communication with the deep veins in the leg in 189 limbs (31.9%). 176 (93.1%) were female and 13 limbs (6.1%) were male. Varicose veins arising from proximal tributaries occurred in 71 limbs, 18 communicated with the posterior tributaries, 48 with medial tributaries and 48 had isolated varices (Table 2). Seventeen limbs had reflux traced to more than one source (proximal, medial or posterior) Pelvic communications and veins of the abdominal wall An attempt to further delineate the proximal, posterior and medial patterns of reflux was made by identification of possible pelvic and abdominal wall tributaries as reflux sources. 174 limbs (29.3%) had evidence of communication with the pelvic or abdominal wall tributaries, including 45 limbs with concurrent transfascial reflux. 129 (21.8%) limbs had pelvic or abdominal wall communications as the sole source of reflux. Of these limbs 29 had more than one demonstrable communication with the pelvic or abdominal veins. Therefore a total of 203 communications in 174 limbs were identified with the pelvic or abdominal veins. 156 (89.7%) of these limbs were female. Adequate assessment of both ovarian and both internal iliac veins was achieved in 57 patients in whom pelvic communications were suspected after examination of the leg. No patients had reflux in the right ovarian vein, 39 patients had evidence of reflux in the left ovarian vein, 2 patients had reflux in the left internal iliac vein and 1 patient had reflux in the right internal iliac vein. Therefore 43 (75.4%) of 57 patients had evidence of ovarian or internal iliac vein incompetence. Table 3 shows the patterns of pelvic and abdominal wall communications and the prevalence of pelvic vein reflux with each of these patterns. The higher number of proximal, medial and posterior communications shown in Table 3 compared to Table 2 can be accounted for by the inclusion of those limbs with concurrent transfascial reflux and those limbs with multiple sources of non-transfascial reflux. Deep venous incompetence The patterns of deep venous reflux are illustrated in Figure 2. There were 334 (56.4%) limbs with reflux in the deep veins. The majority of these limbs (267) had reflux confined to the femoral and popliteal veins, proximal to junctional incompetence (Figure 2 a,b,c). Thirty two limbs had reflux in the femoral and popliteal veins, proximal to incompetent gastrocnemius veins (Figure 2 d,e). All of the limbs with reflux in the deep calf veins had incompetent calf perforators and 326 limbs with deep venous incompetence had associated transfascial reflux. Eight limbs had evidence of isolated reflux in the popliteal vein with no evidence of transfascial reflux. Discussion The prevalence of saphenofemoral, saphenopopliteal and perforator incompetence was similar in this study to previous studies 5, 20, 21. Incompetent calf perforators occurred in almost one third of limbs and in 90% of cases occurred in conjunction with more proximal reflux. These findings suggest incompetent calf perforators most likely arise secondary to more proximal reflux 26. One third of limbs with varicose veins had no evidence of an incompetent transfascial communication in the leg. The prevalence of isolated reflux in this study was lower than in previous studies 5, 7 however these studies did not differentiate between pelvic and isolated communications. The cohort in this study had more severe clinical varicosities than the group examined by Thibault which may also account for this discrepancy 7. There is a preponderance of females (93%) in the group with no evidence of transfascial communication which may be in part due to the inclusion of those limbs with pelvic communication in this group. Females may also be more likely to present for cosmetic reasons and therefore have less severe varicose veins as seen in patterns of non transfascial reflux. The majority of limbs with non-transfascial reflux had evidence of communication with the pelvic veins. Varices arising from the vulva and peri-rectal region 26 almost certainly arise from the pelvis. The origin of reflux arising from the proximal tributaries draining the superficial pubic and abdominal areas is less certain. The normal direction of flow in these tributaries is caudal and therefore are not necessarily incompetent, however, flow from these vessels is certainly contributing to reflux in the long saphenous vein. Communication between the pelvic veins and long saphenous vein via the superficial external pudendal vein has previously been demonstrated with venography 12 and the superficial inferior epigastric vein has potential communication with the obturator vein via anastomoses posterior to the pubic bone 27. This study demonstrated an association between pelvic reflux A USTRALIAN & NEW Z EALAND J OURNAL OF P HLEBOLOGY V OLUME 7(2):DECEMBER

4 J Paige, G Heather Clarke, M J Grigg, P A Blombery and GM Somjen and the superficial veins draining the abdominal wall (Table 3). Jiang 13 has observed these tributaries and made a distinction between those tributaries draining the abdominal wall and those draining the pubic area, however there may be considerable overlap between the two groups due to the numerous interconnections between the superficial pubic and abdominal veins. Reflux in the pelvic veins may be suspected if reflux is seen originating from the three proximal superficial tributaries of the long saphenous vein. The pathway between these tributaries and the pelvic veins is difficult to demonstrate with duplex ultrasound, and venography may be required to clarify these patterns when treatment of the pelvic veins is contemplated. Deep venous incompetence was a common finding in patients with varicose veins and in most cases occurred in a segmental fashion, proximal to a transfascial escape point. Extensive deep venous incompetence involving femoral, popliteal and calf veins was rare in the group of patients studied. Only 8 limbs had deep venous incompetence in the absence of a transfascial communication with the superficial veins usually confined to the popliteal vein which is regarded as a benign condition 29. Combined deep and superficial reflux occurred in specific, directly related veins and generalised incompetence of the deep and superficial veins was uncommon. Reflux was seen in the common femoral vein proximal to saphenofemoral incompetence and in the popliteal vein proximal to saphenopopliteal incompetence but not in the deep veins immediately distal to the junction. Whether this pattern arises due to increased pressure in the popliteal vein rendering the saphenopopliteal junction incompetent, or whether the incompetent junction results in reflux in the popliteal vein is yet to be determined, but evidence exists to support both theories 14-17, 19. The findings of this study demonstrate the complexity of primary varicose veins and the dynamic interaction between deep, superficial and pelvic veins, refuting the original simplistic concept of descending progression of reflux in the aetiology of varicose veins. These patterns should be recognised by clinicians and sonographers to ensure appropriate diagnosis and management. Bibliography 1.Ludbrook J. Valvular defect in primary varicose veins. Cause or effect? Lancet 1963(Dec 21): Moore HD. Deep venous valves in the etiology of varicose veins. Lancet 1951;2: Trendelenburg F. Ueber die unterbindung der vena saphena magna bie unterschenkel varicen. Beitr Klin Chir 1890;7: Fegan WG, Kline AL. The cause of varicosity in the superficial veins of the lower limb. B J Surg 1972;59: Abu-Own A, Scurr JH, Coleridge-Smith PD. Saphenous vein reflux without incompetence at the saphenofemoral junction. Br.J.Surg 1994;81: Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Mansour A, et al. Nonsaphenous superficial vein reflux. J Vasc Surg 2001;34: Thibault P, Bray A, Wlodarczyk J, Lewis W. Cosmetic Leg veins : Evaluation using duplex venous imaging. J Dermatol Surg Oncol 1990;16: Somjen GM, Donlan J, Hurse J, Bartholomew J, Johnston AH, Royle JP. Venous reflux at the sapheno-femoral junction. Phlebology 1995;10: Cavezzi A. Diagnostic de l insuffisance veineuse superficielle des membres inferieurs par echo-doppler-coleur. Phlebologie 2000;53: Dixon JA, Mitchell WA. Venographic and surgical observations in vulvar varicose veins. Surgery, Gynaecology and Obstetrics 1970;131: Dodd H, Wright HP. Vulval varicose veins in pregnancy. B M J 1959;1: Craig O, Hobbs JT. Vulval phlebography in the pelvic congestion syndrome. Clinical Radiology 1974;25: Jiang P, Rij AMv, Christie RA, Hill GB, Thomson IA. Non-saphenofemoral venous reflux in the groin in patients with varicose veins. Eur J Vasc Endovasc Surg 2001;21: Kistner RL. Primary venous valve incompetence of the leg. AM J Surg 1980;140: Raju S. Venous insufficiency of the lower limb and stasis ulceration : changing concepts and management. Ann Surg 1983;197: Almgren B, Eriksson I. Primary deep venous incompetence in limbs with varicose veins. Acta Chir Scand 1989;155: Walsh JC. Femoral venous reflux abolished by greater saphenous vein stripping. Ann Vasc Surg 1994;8: Goren G, Yellin AE. Primary varicose veins: Topographic and haemodynamic correlations. J Cardiovasc Surg 1990;31: Sales CM. Correction of lower extremity deep venous incompetence by ablation of superficial venous reflux. Ann Vasc Surg 1996;10: Guex JJ, Hiltbrand B, Bayon JM, Henri F, Allaert FA, Perrin M. Anatomical patterns in varicose vein disease: a duplex scanning study. Phlebology 1995;10: Quigley FG, Raptis S, Cashman M, Faris IB. Duplex ultrasound mapping of sites of deep to superficial incompetence in primary varicose veins. ANZ.J.Surg 1992;62: Myers KA, Ziegenbein RW, Zeng GH, Matthews PG. Duplex ultrasound scanning for chronic venous disease : patterns of venous reflux. J Vasc Surg 1995;21: van Bemmelen PS, Bedford G, Beach K, Strandness DE. Quantitative segmental evaluation of venous valvular reflux with duplex ultrasound scanning. J Vasc Surg 1989;10: Richardson GD, Beckwith TC, Mykytowycz M, Lennox AF. Pelvic congestion syndrome : Diagnosis and treatment. Australian and New Zealand Journal of Phlebology 1999;3: ad hoc committee - American Venous Forum. Classification and grading of chronic venous disease in the lower limbs - a consensus statement. Vascular Surgery 1996;30(Jan/Feb): Tibbs DJ. Superficial vein incompetence : further considerations. In: Varicose veins and related disorders. Oxford: Heinnemann Butterworth; p Williams PL, Warwick R, Dyson M, Bannister LH. Angiology. In: Gray s Anatomy. Edinburgh: Churchill Livingstone; p Browse NL, Burnand KG, Irvine AT Wilson NM. Surgical treatment of varicose veins. In: Diseases of the veins. London: Arnold; p Somjen GM, Royle JP, Fell G, Roberts AK, Hoare MC, Tong Y. Venous reflux patterns in the popliteal fossa: J Cardiovascular Surgery 1992;33: V OLUME 7(2):DECEMBER 2003 AUSTRALIAN & NEW Z EALAND J OURNAL OF P HLEBOLOGY

5 Table 1. Age, gender and clinical severity in relation to the distribution of reflux. Venous reflux patterns in primary varicose veins: ultrasound findings Number Mean age Percentage of limbs Percentage of limbs (years) with clinical CEAP 4,5,6 of females All limbs % 78.5% Limbs with transfascial reflux % 71.7% Limbs with non-transfascial reflux % 93.1% Table 2. Prevalence of various patterns of both transfascial and non-transfascial reflux. Pattern of reflux Number of limbs Prevalence (Total = 592) (% of total limbs) Transfascial Saphenofemoral Calf perforators Saphenopopliteal Thigh perforators Popliteal fossa perforators Non-transfascial Proximal Isolated Medial Posterior Table 3. Prevalence of pelvic vein reflux in a group of patients with possible communication to the pelvic and/or abdominal wall veins. ( Note:The number of proximal, medial and posterior communications is higher than in Table 2 due to the inclusion of limbs with multiple sources of reflux.) Pattern of reflux Number of limbs Number of limbs with (percentage of all limbs n = 592) associated pelvic reflux (percentage of each pattern of reflux) Proximal Superficial inferior epigastric vein 36 (6.1%) 6 (33.0%) Superficial circumflex iliac vein 19 (3.2%) 10(70.0%) Superficial external pudendal vein 45 (7.6%) 22 (81.8%) Total 100 (16.9%) 38 (72.1%) Medial Vulva, perineal area 69 (11.7%) 32 (78.1%) Posterior Peri-rectal, gluteal muscles 34(5.7%) 14(85.7%) A USTRALIAN & NEW Z EALAND J OURNAL OF P HLEBOLOGY V OLUME 7(2):DECEMBER

6 J Paige, G Heather Clarke, M J Grigg, P A Blombery and GM Somjen SPI + pelvic SFI + SPI + CP 7 7 PATTERN OF REFLUX SFI + pelvic SFI + SPI SPI + CP pelvic + CP SFI + CP NUMBER OF LIMBS Figure 1: Diagram showing the main proximal tributaries of the long saphenous vein. SE = superficial inferior epigastric vein, SCI = superficial circumflex iliac vein, SEP = superficial external pudendal vein, DEP = deep external pudendal vein, MAS = medial accessory saphenous vein, LAS = lateral accessory saphenous vein, LSV = long saphenous vein, F = femoral vein. (Modified from Browse and Burnand 28 ) Figure 2: Limbs with multiple sources of reflux. (SFI - saphenofemoral incompetence, SPI - saphenopopliteal incompetence, CP - calf perforators.) Figure 3: Patterns of deep venous incompetence. (Total number of limbs with deep venous incompetence = 334). Key : = Deep venous reflux = Superficial reflux = No reflux 16 V OLUME 7(2):DECEMBER 2003 AUSTRALIAN & NEW Z EALAND J OURNAL OF P HLEBOLOGY