Frequency of refluxive tributaries of the junction region in the groin in patients with recurrent varicose veins of the thigh

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1 Original article 149 Frequency of refluxive tributaries of the junction region in the groin in patients with recurrent varicose veins of the thigh S. Reich-Schupke 1 ; E. Mendoza 2 ; M. Dörler 1 ; M. Stücker 1 1 Department of Dermatology, Venerology and Allergology; Vein centre of the Departments of Dermatology and Vascular Surgery, Ruhr-University; Bochum, Gemany; 2 Vein Centre; Wunstorf, Germany Keywords Recurrence, saphenofemoral junction, varicose veins, duplex Summary Background: A long stump and neovascularisation are commonly discussed reasons for recurrence of varicosis in the groin after disconnection of the saphenofemoral junction (SFJ) and stripping of the great saphenous vein (GSV). A third possible reason for recurrence with non femoral reflux emerging from tributaries of the junction region, is often underrated. The aim of the study was to report on the source of reflux for recurrent varicose veins of the thigh in patients who already had a history of disconnection of the SFJ and stripping of the GSV. Methods: In this two-centre study, consecutive patients with a history of disconnection of the SFJ, stripping of the GSV and visible or palpable varicose veins of the thigh region were included. Their data and venous diagnostics (DPPG, duplex scan) were recorded and evaluated by a standardised protocol. Correspondence to Priv.-Doz. Dr. Stefanie Reich-Schupke Königswall 16 18, D Recklinghausen/Germany Tel / , Fax / stefanie.reich-schupke@rub.de Results: 101 legs were included. In 58.4 % there was a long stump of the GSV as a source for variose veins of the thigh. In the other legs (42,6 %) the source for the reflux was not a long stump with contact to the femoral vein but residual tributaries of the SFJ, e.g. the superficial epigastric vein or the superficial circumflex iliac vein. Conclusions: Residual refluxive tributaries of the SFJ seem to be an important source for recurrent varicose veins of the thigh. Further prospective studies should focus on suitable therapeutic options. Schlüsselwörter Rezidiv, saphenofemorale Junktion, Varizen, Duplexsonographie Zusammenfassung Hintergrund: Ein langer Stumpf und Neovaskularisation werden vielfach als Gründe für eine Rezidivvarikose nach einer Krossektomie der saphenofemoralen Junktion (SFJ) und einer Saphenektomie der V. saphena magna Häufigkeit refluxiver Seitenäste der Leistenkrosse bei Patienten mit einer Rezidivvarikose des Oberschenkels Phlebologie 2016; 45: Received: December 26, 2015 Accepted: March 9, 2016 (VSM) diskutiert. Eine dritte, oft unterschätze Ursache für ein refluxives Rezidiv sind refluxive Krossenseitenäste. Das Ziel der Pilotstudie war es, duplexsonografisch die Refluxquelle in der Leistenregion bei Patienten mit einer Rezidivvarikose des Oberschenkels nach einer anamnestisch erfolgten Cross- und Saphenektomie der VSM zu detektieren. Methoden: In zwei Studienzentren wurden konsekutiv Patienten, die anamnestisch eine Cross- und Saphenektomie der VSM hatten, und nun eine sichtbare oder palpable Rezidivvarikose des Oberschenkels aufwiesen, in die Studie eingeschlossen. Ihre Daten sowie die venöse Diagnostik (DPGG, Duplexsonografie) wurde entsprechend einem standardisierten Protokoll dokumentiert und ausgewertet. Ergebnisse: 101 Beine wurden inkludiert. Bei 58,4 % konnte ein überlanger Stumpf der Vena saphena magna nachgewiesen werden, aus dem sich Varizen am Oberschenkel speisten. Bei den übrigen 42,6 % jedoch speisten sich die Varizen im Oberschenkelbereich nicht über einen überlangen Stumpf mit Kontakt zur Vena femoralis, sondern aus den residualen Krossenseitenästen wie z. B. der Vena epigastrica superficialis oder der Vena circumflexa ilium superficialis. Schlussfolgerungen: Bei einer Rezidivvarikosis mit Varizen am Oberschenkel scheinen die Residuen refluxiver inguinaler Krossenseitenäste eine wichtige Rolle zu spielen. Weitere prospektive Studien sollten analysieren, welche Therapie für diese Form der Rezidivvarikose am effizientesten ist. Introduction Chronic venous disease (CVD) is a chronic and progressive disease. Affected patients often develop recurrent varicose veins and telangiectasias during the course of the disease. The incidence and the severity of CVD increase by age (1). Besides the progression of the underlying disease itself, there is furthermore the possibility of recurrence of varicose veins after therapeutic interventions. That is known for all kinds Schattauer 2016 Phlebologie 3/2016

2 150 S. Reich-Schupke; E. Mendoza; M. Doerler; M. Stuecker: Tributaries of the junction region in the groin Tab. 1 Classification of anatomical patterns of recurrent varicose veins in the groin, proposal of the Edinburgh group (7). Type 1 = intact saphenofenoral complex 1A intact great saphenous vein 1B intact tributaries 1C neovascularisation of surgical and interventional treatment (2, 3). Within the last years there have been intensive efforts in research and multicentric studies focusing on recurrent veins of the groin after flush disconnexion and stripping of the GSV (4 6). According to the classification of the Edinburgh group there are 2 types of recurrent varicose veins in the groin that can be further devided into sub-groups (7, Table 1). In particular two main reasons for recurrence in the groin are widely discussed: a) imperfect surgery of the saphenofemoral junction with a too long and still refluxive stump and b) the development of neovascularisation after a correct flush disconnexion (4, 5, 8). These two types can be differentiated in the explanted junctional preparation by using histological or immunhistological examinations (4, 9). The intraoperative clinical estimation of the surgeon or the pre-surgical examination by ultrasound are less adequate for the correct diagnosis (5, 6). During the last years the role of refluxive epigastric, circumflex or pudendal veins Inclusion criteria Age >18 years Type 2 = obliterated saphenofemoral complex 2A cross-groin connection 2B thigh perforators Medical history with flush disconnection and stripping of the great saphenous vein in the groin; multiple surgery was admitted; >1 year since last surgery Visible or palpable varicose veins at (at least one) thigh Written informed consent after detailed information about the study of the goin in the development of recurrent varicose veins of the thigh has been largely ignored (10). Furthermore, it should be examined whether the bundle of small, irregular tortuous, refluxive veins that is often regarded as typical for neovascularisation is in fact associated with neovascularisation or if it is perhaps caused by remaining refluxive tributaries of the groin. The aim of the current study was to examine the source of reflux (femoral/ non femoral) for varicose veins of the thigh after previous flush disconnexion and stripping of the great saphenous vein (GSV). Patients and methods In two duplex-experienced German vein centres (Bochum & Wunstorf) consecutive patients who presented for diagnostics of varicose veins were included in the study if they met the criteria of Table 2. The medical history and the findings of the clinical examination and the ultrasound were documented by a standardised questionnaire. Diagnostics Exclusion criteria Wish of the patient not to take part in the study Acute deep or superficial vein thrombosis Tab. 2 In- and exclusion criteria. All patients had a duplex scan and a digital photoplethysmography (DPPG) on both legs. In some patients an additional venous occlusion plethysmography (VVP) was performed. In the duplex scan (Bochum: Siemens, Accuson 3000, linear probe 10,5MHz; Wundstorf: Fuji Fazaone, linear probe 5 10MHz.) the emphasis was on the findings of varicose veins in the groin with detection of the origin of the reflux following diverse provocation maneuvers, like manual compression of the calf or Wunstofer maneuver (11). It should be documented if there was a stump or signs for neovascularisation. The reflux source was documented either femoral or from tributaries or both. Furthermore the diameter of the maximum refluxive vessel in the groin and the presence of a groin varicose network should be reported. Additionally, it was documented if the complete vessel or parts of the GSV were in situ. Ethics The protocol of the study followed the Helsinki Declarations and was approved by the ethics committee of the Ruhr-University Bochum (No ) and for Wunstorf confirmed by the second committee of Hannover. Statistics The data was documented in Excel 2003, Microsoft. For statistical analyses (bilateral correlation of Pearson and Chi-square test) SPSS Statistics 19 was used. A p<0.05 was regarded as significant. Results Patients Altogether, 101 legs (= patients) were included (91 female, 10 male; 42 right, 59 left). The average age was 58.8 ± years (26 86 years). The patients had an average weight of kg ( kg), an average height of cm ( cm) and a resulting body mass index (BMI) of kg/m 2 ( kg/m 2 ). The maximum clinical class according to the CEAP classifiation varied between 1 6 ( Figure 1). Current symptoms In 71.3 % of the patients CVD was symptomatic with heaviness (52.5 %) or pain in the legs (26.7 %). There were no significant differences between men and women according to the symptoms. There was a significant correlation of the symptoms (p=0.048) and the maxium C-class Phlebologie 3/2016 Schattauer 2016

3 S. Reich-Schupke; E. Mendoza; M. Doerler; M. Stuecker: Tributaries of the junction region in the groin 151 (p=0.007) with the BMI. Additionally the maximum C-class had a significant correlation with the presence of symptoms (p<0.001). Previous surgery The average number of previous surgical procedures in the groin was 1.41 ± 0.76 (1 5). Mostly, there was one (71.3 %), in some cases there was a history of two previous surgical interventions (20.8 %) in the groin. The scar of the previous crossectomy was in the groin in all patients. In one case there was an additional scar distal to the groin region. Diagnostics The venous refilling time was seconds on average with a wide range of 0 to 48 seconds. The maximum C-class correlated with the venous refilling time (p=0.029). Stump and groin varicose network In 58.4 % of all legs a stump of the great saphenous vein could be detected by ultrasound; in 51.1 % of the patients a reflux could be found in the stump (type 1A and 1B according to 7). The origin of this reflux came from the femoral vein in 55.5 % (type A according to 7), but in in 42.6 % it was non-femoral but came from other epigastric, pudendal or circumflex veins of the groin (type B according to 7). In 4 patients there was more than one origin of the reflux of the stump. The maximum diameter of the largest recurrent vein in the groin (stump or vein network) had a wide range ( Figure 2) with an average of 5.5 mm. Clinical symptoms like heaviness and/or pain were significantly associated with a detectable reflux in the groin region. There was no difference according to the origin of the reflux (femoral p=0.031 or non-femoral p=0.05). Visible varicose veins at the thigh and in the groin region In 14 legs there were no visible varicose veins in the medial thigh region. In 47 legs Fig. 1 Distribution of the maximum C-class according to the CEAP classification in all legs. there were varicose veins lateral to the groin, in 27 in the pudendal region, in 43 an anterior accessory vein and in 2 patients in the groin region. An in-situ GSV and thus an incomplete exhairesis within the previous surgery was detected in 13 legs in the thigh and in 3 legs within the complete leg. The maximum diameter of the left GSV was documented for 4 patients with an average of 9.3 mm. Discussion The results presented show that about 43 % of the patients with visible/ palpable recurrent varicose veins of the groin and the thigh after previous surgery of the SFJ have no reflux origin from the femoral vein but from tributaries of the groin. It can be debated whether this high rate is typical for recurrent varicose veins or if it is also detectable in primary varicose veins without previous surgery in the groin. Secondary findings of other studies allow the assumption that such refluxes are present Fig. 2 Distribution of the maximum diameter of the detectable vein in the groin (varicose network or stump) in mm. before primary surgery. In a British study 20 % of the examined female patients with varicose veins of the leg had a reflux with no origin in the femoral vein (12). Mendoza et al. detected a reflux in tributaries of the groin in 30 % of 137 patients without previous surgery (13). A current Polish study shows more than one reason (stump, neovascularisation, tributaries of the groin) for a groin recurrence of no fewer than 15.5 % of patients (14). These authors concluded that the primary suboptimal crossectomy with a long stump or left tributaries of the groin are the main reasons for a recurrence of varicose veins in the groin (14). Limitations The authors are aware that this study has strong limitations because it is not consequently prospective. We only have the patients history of the prior interventions and we did not see the original status of the groin before the first intervention. Furthermore the group of patients is very heterogenous according the type of prior intervention, the time since last intervention Schattauer 2016 Phlebologie 3/2016

4 152 S. Reich-Schupke; E. Mendoza; M. Doerler; M. Stuecker: Tributaries of the junction region in the groin and the number of prior interventions. Another prospective study would be necessary to recheck the current findings. However, the results of this study give an interesting hint to have a closer look to groin tributaries prior to surgery in further studies. The impact of the groin varicose network Furthermore it has to be discussed if the groin varicose network in recurrence is typical for neovascularisation or if it is related to and promoted by refluxive tributaries of the groin after sapheno-femoral surgery. The patients in the present study show a significant correlation between a groin varicose network and a reflux of tributaries. This finding should also be part of a further prospective study. The data presented emphasise the importance of an accurate duplex scan before venous surgery to detect the primary origin of the reflux in the groin (femoral vein or tributaries). Without a thorough duplex scan of the groin, a higher risk for a rapid recurrence is predestined and an analysis of recurrence reasons is not really possible. According to Stücker there are 3 different types of primary insufficiency of the sapheno-femoral junction that should be precisely defined in the pre-surgical examination (10): Type 1: Incompetent terminal, but competent pre-terminal valve (reflux escaping through anterior or posterior accessory saphenous vein) Type 2: Competent terminal, but incompetent pre-terminal valve (reflux fed by inguinal tributaries not by the deep vein) Type 3: Incompetent terminal and preterminal valve (complete incompetence, origin of reflux from the deep vein filling the GSV) It can be discussed if patients with a groin varicose network in recurrence and reflux of tributaries in the groin perhaps never had any real sapheno-femoral insufficiency with incompetence of the terminal and pre-terminal valves (type 3), but a type 2-insufficiency with reflux of inguinal tributaries that was not detected in pre-surgical diagnostics and finally not correctly and causally treated in the surgical intervention by a disconnection of these tributaries. Others could debate that especially because of a complete disconnection of tributaries the recurrence will develop. They could propose, that leaving the refluxive tributaries draining into the deep veins after thermal ablation of GSV would reduce these recurrences. Finally, further studies are neccessary to verify or falsify these hypothesis by evidence and to find which treatment options suites the best to which pre-surgical situation. Questions for further studies The impact of tributaries and the development of reflux within these branches should be the aim of a prospective study. Conclusion The data show that about 40 % of the patients with either a duplex-detected stumprecurrence or a duplex-detected varicose networks of the groin and visible/ palpable varicose veins on the upper leg have a reflux, that does not originate from the femoral vein, but from tributaries of the sapheno-femoral junction. Furthermore, there is a significant association between the presence of a groin varicose network and the presence of refluxive tributaries. According to these findings, diagnostic procedures before and after therapeutic interventions should focus on a more accurate description of tributaries of the sapheno-femoral junction and the origin of the reflux. Perhaps, a more differentiated observation of the origin of the reflux in the groin (femoral vs. tributaries) could contribute to increase the knowledge on the pathogenesis of recurrence and help to optimise the therapy of varicose veins. However, the limitations of the current study do not allow a generalisation of the findings, but the findings give a hint for further studies focussing on a sorrow description of the vessel situation in the groin pre-interventional (where is the original of the reflux?), short after the treatment (e.g. 1 month, correct treatment? No remaining reflux?) and long after the intervention (e.g. 5 years, signs of neovascularisation?). There should be a focus on the presence or development of reflux in the tributaries before any surgery or in the follow up after surgery. This has to be clarified. Is the terminal valve is competent? Is the preterminal valve is competent? Was there any reflux in tributaries of the groin before surgery lasting longer than 1 second? How far were pre-existing tributaries diminished within surgery? Do dectable tributaries in the groin develop or grow after saphenofemoral surgery? Do detectable tributaries become refluxive in the follow-up period after surgery? Which type of clinical relevant recurrence develops from the refluxive tributaries of the groin? Tributaries of the groin could have special impact not only in venous surgery but especially in endothermal ablation (EA) where junctional tributaries are not treated and a stump may be left. Important guidelines of the US and the NICE recommend EA rather than venous surgery (15, 16). It would be interesting, if, after EA there are also refluxive tributaries in the groin in the case of recurrence. Furthermore, it should be investigated, what happens to refluxive tributaries already existing before the treatment. Do these patients have a fast recurrence? Conflict of interest The authors declare no conflict of interest. Ethical guidelines The study was conducted according to national guidelines and the current declaration of Helsinki. References 1. Rabe E, Pannier-Fischer F, Bromen K, Schuldt K, Stang A, Poncar C, Wittenhorst M, Bock E, Weber S, Jöckel KH. Bonner Venenstudie der Deutschen Gesellschaft für Phlebologie: Epidemiologische Untersuchung zur Frage der Häufigkeit und Ausprägung von chronischen Venenkrankheiten in der städtischen und ländlichen Wohnbevölkerung. Phlebologie 2003; 32: Phlebologie 3/2016 Schattauer 2016

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