Correlation of the anatomical distribution of venous reflux with clinical symptoms and venous haemodynamics in primary varicose veins

A systematic review of anatomical reflux patterns in primary chronic venous disease

OBJECTIVE

Patients with chronic venous disease (CVD) can present with different underlying hemodynamic abnormalities affecting the deep, superficial, and perforator veins. This review explores the relationship between reflux patterns, extent of venous reflux, and clinical manifestations of CVD.

METHODS

The Medline and EMBASE databases were searched systematically from 1946 to April 1, 2024. References of shortlisted papers were searched for relevant articles. Studies were included if they were in English language, included participants ≥16 years of age, documented reflux patterns in two or more of the following: deep, superficial, and/or perforator systems, and related patterns to presentation or severity. Exclusion criteria included patients with isolated deep venous thrombosis, post-thrombotic syndrome or stenotic or obstructive disease.

RESULTS

We identified 18 studies (11,177 participants; range, 55-3016). Meta-analysis showed significant odds ratios (OR) for C4-6 disease being associated with deep reflux (OR, 2.41; 95% confidence interval [CI], 1.53-3.78) and perforator reflux (OR, 3.37; 95% CI, 2.16-5.27), but not superficial reflux (OR, 2.11; 95% CI, 0.87-5.14), vs C0-3 disease. Severe CVD (C4-6) was significantly associated with isolated deep, combined deep and superficial, and combined superficial and perforator reflux. The greatest risk of CVD progression (defined as de novo development of varicose veins and progression to greater CVD severity) was shown by two studies to be related to combined deep and superficial reflux.

CONCLUSIONS

Although limited by the heterogenous nature of the studies, this review confirms that reflux pattern is a significant predictor of clinical class, and higher clinical, etiological, anatomical, and pathophysiological stages are associated with a higher prevalence of superficial, deep, and perforator reflux. Isolated deep and combined reflux also seem to be to predict the onset of leg ulceration. Future studies should relate reflux patterns to treatment outcomes, including recurrence risk. This work could help to inform health policies and management guidelines so that reflux patterns, in conjunction with other demographic and hemodynamic parameters, could be used to risk stratify patients and identify individuals who may benefit from earlier treatment.

A Study of Valvular Incompetencies in the Lower Limb Veins Using Doppler Ultrasound Findings

INTRODUCTION

Varicose veins (VV) are one of the most common pathologies associated with the venous system of the lower limb. In the Indian population, its incidence is higher, and it is one of the most commonly encountered cases in the hospital. The study aimed to note the widely affected anatomical structure in male and female varicose patients using Doppler ultrasound (DU) examination findings.

METHODS

A total of 200 Doppler ultrasound reports of varicose patients were retrospectively analyzed and categorized based on the affected structure. The demographic data of all cases, such as age, sex, brief history, signs, symptoms, and affected side of the lower limb, was noted. Anatomical structures causing venous refluxes in the saphenous systems, junctions, and perforating venous systems were noted. Pearson's correlation coefficient was applied to find out its association.

RESULTS

Out of 200 Doppler reports studied, 133 (67%) were male and 67 (33%) were female patients. The majority, 180 (90%) cases, belonged to C1-C3 stages according to the Clinical, Etiology, Anatomy, and Pathological (CEAP) classification, while 20 (10%) were in C4-C5 stages. Male patients aged between 31 and 40 years were predominantly affected, with their left side being affected most commonly. In female patients, the older age group of 50-60 years was predominantly affected. Great saphenous reflux in the groin due to incompetent terminal valve was noted in 126 (63%) cases. In the perforator venous (PV) system, defects in the medial leg perforator (189 (95%)), posterior leg (92 (46%)), and thigh perforator (20 (10%)) were noted.

CONCLUSION

In the present study, the occurrence of varicose veins is due to the involvement of superficial, deep, and perforator veins with varying percentages. Among the structures, the medial leg perforator was predominantly involved, followed by other perforators. Since most patients were in C1-C3 stages, the involvement of deep veins was noted minimally.

Saphenous reflux patterns in C2 patients: A record of 1196 ultrasound reports

Objectives

To describe saphenous reflux patterns in patients classified as CEAP C2 by analysis of 2027 vascular ultrasound examination reports.

Methods

A total of 2027 venous mapping studies were reviewed and 1196 patients classified as CEAP C2 were selected. Patients were classified according to patterns of reflux for the great saphenous vein and for the small saphenous vein, and rates of great saphenous vein and small saphenous vein reflux were analyzed for both sexes.

Results

The overall prevalence of saphenous vein reflux was 45%. Males had significantly higher great saphenous vein reflux prevalence than females ( p < 0.001). The most common great saphenous vein reflux pattern in females was segmental reflux and the most common pattern in males was proximal reflux.

Conclusions

Saphenous vein reflux is common in C2 patients and is more frequent in males. Standardization of classifications of reflux patterns is very important for correct management of the disease.

Persistent incompetent truncal veins should not be treated immediately

Background

The traditional attitude for the treatment of chronic venous disorder is to systematically treat incompetent truncal veins. We wanted to evaluate the outcomes of not treating all incompetent truncal veins with regard to our experience of focusing the treatment to the varicose tributaries.

Methods

Retrospective study on all procedures of surgical treatment consecutively performed for varicose veins by single phlebectomy with preservation of a refluxing great saphenous vein (GSV), according to the principles of the ambulatory selective varices ablation under local anesthesia (ASVAL) during four years of practice. The clinical and hemodynamic outcomes have been evaluated at eight days, one year, and once a year.

Results

We have included 1212 lower limbs (LLs) that underwent consecutive ASVAL procedures in 816 patients (611 women and 205 men) aged between 19 and 93 years (mean age 53.7 years). The CEAP Class C classification was C0–C1 = 0%; C2 = 85.6%; C3 = 5.4%; C4 = 7.8%; C5 = 0.7%; C6 = 0.7%. Symptoms were present in 854 cases (70.5%). A thrombosis of the GSV was diagnosed at eight days postoperative in 13 cases (1.1%). A total of 1010 LLs were followed after the first postoperative year (mean follow-up of 44.5 months). A secondary major procedure was done in 30 cases during the follow-up: a striping of the GSV in nine cases and a redo phlebectomy in 21 cases. The cumulative incidence of a persistent or recurrent GSV reflux, of a varicose recurrence, and of secondary major procedure at five years after life table analysis was 33.8%, 13%, and 4.5%, respectively. A GSV reflux extended above plus below the knee and multiple connections of the varicose tributaries to the GSV at the calf were associated with a varicose recurrence (respectively 66.7% versus 55.3% p < 0.05 and 46.7% versus 12.8% p < 0.05).

Conclusion

A treatment limited to the varicose tributaries by phlebectomy is safe and efficient at midterm with preservation of the main veins of the superficial venous system. It can be performed in a large group of patients thanks to a proper exclusion of cases with advanced chronic venous disorder. Therefore, the systematic treatment of an incompetent truncal vein is not relevant in the majority of the cases.

Influence of the competence of the sapheno-femoral junction on the mode of treatment of varicose veins by surgery

Background

It is usually agreed that incompetence of the sapheno-femoral junction (SFJ) is the main indication for stripping or ablation of the great saphenous vein (GSV) in the treatment of varicose veins (VVs). We wanted to test this assumption in our surgical treatment of varicose veins.

Methods

Study design: retrospective study of the surgical procedures for VVs in our centre between January and October 2012 in patients with reflux in the GSV. The SFJ was considered to be incompetent when both terminal and pre-terminal valves were assessed as incompetent by duplex ultrasound duplex imaging. We compared the preoperative clinical and haemodynamic data according to the surgical procedure performed.

Results

We reviewed a total of 389 LLs operated on for VVs in which reflux was present in the GSV. The SFJ was incompetent preoperatively in 189 LLs (48.6%). The GSV was treated in 78 cases (20.1%) stripping in 24 cases and radiofrequency ablation (RFA) in 54 cases, while phlebectomy with preservation of the GSV (ASVAL = Ambulatory Selective Varices Ablation under Local Anaesthesia) was done in the 311 remaining cases (79.9%). Incompetence of the SFJ led to stripping or RFA of the GSV in 38.1% of the cases only. Treatment by stripping or RFA was associated with male gender (50% vs 18.9% P < 0.01 χ2), an older age (62.5 vs 53.1 yrs P < 0.01 t-test), a greater body mass index (BMI) (26.1 vs 23.8 P < 0.01 t-test), a higher frequency of CEAP Class C4 to C6 (33.3% vs 4.8% P < 0.01 χ2), a higher frequency of symptoms (94.4% vs 73.6% P < 0.01 χ2) and a greater diameter of the GSV at the thigh (8.1 vs 5.2 mm P < 0.01 t-test). At last the presence of a focal dilatation of the GSV and an extension of the reflux below the lower half of the calf were also more frequent in case of stripping or RFA (respectively 55.6% vs 10.3% and 84.6% vs 18.3% P < 0.01 χ2).

Conclusion

An incompetent SFJ was not the only clinical feature which determined the choice for preservation or ablation of the GSV in patients with varicose veins. In our experience a greater age, a higher BMI, the presence of trophic skin changes, extension of the reflux below the knee and a more damaged GSV trunk were also taken into account in order to decide whether to ablate or to preserve the GSV.

Patterns of reflux in the great saphenous vein system

Objective:

To report the patterns of reflux in the great saphenous vein as well as to investigate the correlations between patterns of reflux, the demographics and the clinical findings in the population studied.

Methods:

A total of 1882 limbs were assessed by duplex ultrasound examination in 1449 patients (348 men and 1101 women). Ages ranged from 21 to 94 years (mean 51.8). The presence of symptoms of venous disease (aching, heaviness, night cramps, swelling, itching, burning, tingling and throbbing) and clinical signs were recorded.

Results:

Varicose veins without saphenous reflux occurred at a younger age (43 versus 55.6 years P < 0.05). The presence of incompetence at the saphenofemoral junction occurred in older patients (58.5 versus 54.1 years P < 0.05). Venous reflux to the ankle also occurred in older patients (mean 64.0 years P < 0.05). Saphenous vein reflux without clinical varices was associated with more advanced signs (C4–C6: 20.3% P < 0.05). A younger age was associated with less advanced signs (C0–C2:49.4 versus C4–C6: 60.1 years P < 0.05). Presence of symptoms was associated with advancing patient age (51.1 versus 49.1 years P < 0.05).

Conclusions:

A significant correlation between the extent of great saphenous vein reflux and the patient age and the clinical stage of SVI has been observed in this study. The authors hypothesize that these findings support the concept of early treatment of venous insufficiency before symptomatic and physiological deterioration occurs.

Patterns of short saphenous vein incompetence

The significance of short saphenous vein (SSV) reflux is an under-explored territory in chronic venous disease (CVD). We have examined the origin and significance of SSV reflux in primary and secondary CVD. While the natural history of SSV incompetence remains uncertain, its prevalence has been shown to approximate 3.5%, rising with progressing clinical venous insufficiency, and bears an association with lateral malleolar venous ulceration. The most common pattern of reflux extends throughout the SSV Patterns of incompetence in recurrent disease are highly variable, but SSV reflux may itself pose a risk for recurrence, in part due to the complex anatomy of the saphenopopliteal system. Further studies are required to delineate the impact of SSV reflux in secondary venous disease and deep venous incompetence.

External banding valvuloplasty for incompetence of the great saphenous vein: 10-year results

OBJECTIVES

External banding valvuloplasty (EBV) of the great saphenous vein (GSV) in patients with varicose veins is still controversial. The present study evaluated the effectiveness of EBV in selected patients with an insufficiency of the GSV after a mean follow-up of 92.6 months.

METHODS

A total of 101 limbs underwent EBV for the treatment of a GSV insufficiency. Thirty-one limbs from 27 patients (three men, 24 women; mean age 44.2 years; range 19 to 58 years) were re-examined and followed for a mean of 92.6 months. The venous volume, venous filling index, ejection fraction and residual venous fraction were analyzed preoperatively and at the follow-up using air plethysmography. The diameter and reflux of the GSV were evaluated using duplex ultrasound.

RESULTS

Overall, the mean (± SD) follow-up time was 92.6±22.3 months (range 46 to 138 months). At the follow-up, the preoperative venous hemodynamic states had improved significantly, to the following values: venous volume 96.0±32.3 mL to 83.4±32.6 mL; venous filling index 3.6±2.9 mL/min to 2.4±2.2 mL/min; and residual venous fraction 39.7%±18.6% to 26.1%±16.8% (P<0.05). The diameter of the GSV was 6.4±1.4 mm preoperatively and 4.8±1.7 mm postoperatively (P<0.01). Reflux in the proximal GSV was demonstrated preoperatively in 19 (61.3%) of 31 limbs. During the follow-up period, four limbs (12.9%) had high ligation and stripping of the GSV performed due to the recurrence of varicosity.

CONCLUSION

EBV of the GSV provides good results in terms of the venous hemodynamics and decreasing the diameter of the GSV. EBV may be an alternative procedure to stripping or endovenous ablation therapy in selected patients.

Patient-reported symptoms are independent of disease severity in patients with primary varicose veins

The objective of this paper is to explore patterns of incompetence and disease distribution in patients with chronic venous disorders and to correlate this with CEAP (Clinical, Etiologic, Anatomic and Pathologic) classification and presenting symptoms to determine which features of chronic venous disorder (CVD) could be used to guide a patient pathway for referral and treatment. Consecutive patients attending a one-stop venous clinic at a university teaching hospital were recruited over a 12-month period. Patients were clinically assessed, assigned CEAP scores, duplex-scanned and categorized. Data were analyzed to identify associations between symptomatology and disease. Four hundred twenty-four limbs were divided into groups A (C2–3) (339) and B (C4–6) (85). The number of men, mean patient age, varicose vein diameter and quality-of-life score (Aberdeen Varicose Vein Questionnaire – AVVS) were significantly higher in group B ( P < 0.01). Ache occurred more commonly in group A and in women ( P < 0.01). Ache and pain were seen more frequently with saphenofemoral junction reflux ( P < 0.05). Group A women were more likely to be offered surgical intervention while men were managed conservatively ( P < 0.05). In conclusion, CVD symptoms are independent of disease severity assessed by CEAP score. Advanced disease is associated with larger venous diameters, older age and corresponds to a poorer quality of life. Objective markers such as CEAP, Venous Clinical Severity Score and AVVS should be used in determining a patient pathway for referral and treatment of CVD.

Classification of saphenous refluxes: implications for treatment

Objective

To determine the possible correlations of patient age, symptoms and signs with findings of Doppler duplex examination in limbs with varicose veins.

Methods

A total of 2275 ultrasound examinations were done on 2275 limbs of 1751 patients (421 men and 1330 women). Ages ranged from 21 to 94 years (mean 50). Symptoms of aching, heaviness, burning pain (venous neuropathy) were recorded, and signs of ankle hyperpigmentation, scars of healed ulcers and presence of open venous ulcers were noted.

Results

Presence of symptoms was associated with advancing patient age (50.7 vs. 48.8 years). Varicose veins without great saphenous reflux correlated with younger age (43 vs. 53.5 years). Presence of saphenofemoral junctional incompetence correlated with an older age (54.7 vs. 49.8 years), and reflux to the ankle (Hach stage IV) also correlated with older age (mean 63.7 years). A younger age was associated with less advanced signs (C0–C2: 49.1 vs. C4–C6: 60.1 years). Saphenous vein reflux without clinical varices was associated with more advanced signs (C4–C6: 21.3%).

Conclusions

Ageing is associated with advancing clinical symptoms, signs and increasing multifocal reflux in limbs with venous insufficiency. These facts support the concept of early treatment of venous insufficiency before predictable deterioration occurs.

[Primary varicose veins: frequency, clinical significance and surgical treatment]

INTRODUCTION

According to the definition of the World Health Organization, varicose veins represent abnormally enlarged superficial veins having baggy or cylindrical shape. The most frequent cause of primary varicose veins is the insufficiency of long saphenous vein (LSV), but especially the basin of its connection with femoral vein and perforating veins.

OBJECTIVE

The objectives of these investigations were: the determination of insufficiency incidence of SSV in cases of LSV insufficiency; the establishment of association of insufficiency of perforating veins of the basin of LSV and SSV; the study of the results of surgical treatment of insufficiency and varicosity of both short and long saphenous veins.

METHODS

In this study, 100 patients (66 women and 34 men), average age 52.1 years, with clinical symptoms showing the insufficiency and varicosity of long saphenous vein with no change of deep vein system were examined. Ultrasonographic examinations were made using Color Doppler probes--7.5 and 3.75 MHz (Toshiba Corevison SSA 350 A); the development of incompetence of long saphenous vein (LSV) and short saphenous vein (SSV) at the level of the junction as well as other incompetent valves were examined. The reflux was defined as a retrograde flow of the duration longer than 0.5 seconds.

RESULTS

The insufficiency of short saphenous vein was determined by ultrasonographic examination in 34%, while the insufficiency of perforating veins in 80% of patients. 40% of patients were operated (33.3% of females, and 52.9% of males). The most frequent indications for surgical treatment of superficial veins insufficiency were: strong varicosities, clear symptoms and signs, superficial thrombophlebitis and conditions after superficial thrombophlebitis. Surgical treatment was applied in 16% of patients due to recurrence in the basin of long saphenous vein, and in 6% of cases because of the recurrence in the basin of short saphenous vein. Data analysis failed to discover any statistically significant difference between the age of patients and varicosities in the basin of long saphenous vein as well as in the basin of short saphenous vein (51.98 +/- 9.97 years; 54.50 +/- 31.82 years; t=0.36; p>0.05), or any significant difference of BMI value, with regard to the obesity of patients and varicosities in the basin of long saphenous vein as well as in the basin of short saphenous vein (28.02 +/- 4.61 kg/m2; 24.50 +/- 6.36 kg/m2; t=0.50; p>0.05). No statistically significant correlation was found between Color Duplex findings of insufficiency of both long saphenous vein and short saphenous vein (p=-0.21; p>0.05), nor any significant correlation of Color Duplex findings of perforating veins insufficiency in the basin of long saphenous vein and short saphenous vein (p=-0.115; p>0.05).

CONCLUSION

The incidence of insufficiency is significant: approximately every third patient has short saphenous vein insufficiency, while three third of patients have perforating veins insufficiency. Color Duplex limb's veins ultrasonography is highly reliable method for the examination and study of superficial veins diseases, which is very important for preoperative decision-making and selection of surgical technique as well as for postoperative follow-up.

Immunocytochemical characterisation of the inflammatory cell infiltrate of varicose veins

OBJECTIVES

To characterise the inflammatory cell infiltrate in varicose vein wall, and its relationship to the valve complex.

DESIGN

A comparative study of the distribution of inflammatory cells in normal and varicose vein.

MATERIALS

Specimens of proximal human long saphenous vein were obtained from patients with duplex Doppler confirmed long saphenous vein reflux (n=14). Control vein was obtained from patients undergoing coronary artery bypass without clinical evidence of venous insufficiency (n=6). Longitudinal 7 microm frozen sections of vein, displaying valve, were prepared.

METHODS

Using immunohistochemistry, T-lymphocytes (CD3), macrophage/monocytes (CD68), neutrophils (CD15s) and mast cells (anti-mast cell tryptase) were identified. The number of cells per unit length vein were counted using light microscopy.

RESULTS

There were significantly more mast cells and macrophage/monocytes in varicose vein as compared to control. There was a non-significant trend towards more T-lymphocytes in varicose vein. Few neutrophils were present in varicose or normal vein. The distribution of inflammatory cells with respect to the valve was not found to be significant.

CONCLUSIONS

Varicose veins display a greater inflammatory cell infiltrate than normal vein. The key role of macrophage/monocytes and mast cells in tissue damage and remodelling should stimulate further research into whether they play a significant role in the development of chronic venous insufficiency.

Correlation of duplex ultrasound scanning–derived valve closure time and clinical classification in patients with small saphenous vein reflux: is lesser saphenous vein truly lesser?

OBJECTIVE

We recently identified small saphenous vein (SSV) reflux as a significant risk factor for ulcer recurrence in patients with severe chronic venous insufficiency (CVI) undergoing perforator vein ligation. In this study we examined the role of SSV reflux in patients across the spectrum of CVI.

METHODS

From March 15, 1997, to December 24, 2002, clinical and duplex ultrasound (US) scanning data from all valve closure time studies performed in our vascular laboratory were prospectively recorded. Valve closure time in the deep and superficial leg veins was assessed with the rapid cuff deflation technique; reflux time greater than 0.5 seconds was considered abnormal. SSV reflux was correlated with the CEAP classification system and eventual surgical procedure. Data were analyzed with Pearson chi(2) analysis.

RESULTS

We analyzed 722 limbs in 422 patients, 265 (63%) female patients and 157 (37%) male patients, with a mean age of 48 +/- 12.8 years (range, 16-85 years). In the entire cohort the cause was congenital (Ec) in 5 patients, primary (Ep) in 606 patients, and secondary (Es) in 112 patients. SSV reflux was present in 206 limbs (28.5%) evaluated. Among limbs with SSV reflux, Ec = 4 (2%), Ep = 162 (79%), and Es = 40 (19%). SSV reflux did not correlate with gender, side, or age. The prevalence of SSV reflux increases with increasing severity of clinical class: C1-C3, 25.8% versus C4-C6, 36.1% (P =.006). SSV reflux is highly associated with deep venous reflux, 35.2% of femoral vein reflux (P =.015), 35.8% of femoral vein plus popliteal vein reflux (P =.001), and 40.5% of isolated popliteal vein reflux (P <.001). Great saphenous vein (GSV) reflux was identified in 483 (67%) limbs studied with valve closure time, whereas SSV reflux was present in 206 (28%) limbs. In this cohort, 127 GSV or SSV surgical procedures were performed subsequent to valve closure time examination. Among these operations 107 (84%) were GSV procedures, and only 20 (16%) were SSV procedures.

CONCLUSION

SSV reflux is most common in patients demonstrating severe sequelae of CVI, such as lipodermatosclerosis or ulceration. The increasing prevalence of SSV reflux in more severe clinical classes and the strong association of SSV reflux and deep venous reflux suggest that SSV may have a significant role in CVI. Our data further show that, in our institution, a GSV with reflux is more than twice as likely to be surgically corrected as an SSV with reflux. It is time for the SSV to assume greater importance in the treatment of lower extremity venous disease. Future improvements in surgical techniques for access and visualization of the SSV may facilitate this method.

Recurrent varicose veins after surgery: a new appraisal of a common and complex problem in vascular surgery

OBJECTIVE

To assess the true incidence, the reflux patterns and the mechanisms responsible for recurrent varicose vein disease according to current definitions and guidelines.

PATIENTS AND METHODS

Ninety-three patients (69 female, 24 male, mean age: 48 years) were prospectively evaluated pre- and postoperatively (1 month and 5 years), using clinical and colour duplex examination of both lower limbs. The CEAP score and its modification for recurrence (REVAS) were used for classification.

RESULTS

In 113 operated lower limbs, 28 (25%) were found to have a recurrence, 20 of which were symptomatic (20/28, 72%). However, in this group, the mean severity score decreased significantly from 6.5 (SD 3.1) to 5.2 (SD 2.8) (p<0.001, paired t-test). The correlation between the type and cause of recurrence revealed: (1) true recurrent varices in eight limbs (8/28, 29%), primarily caused by neovascularisation, (2) new varicose veins as a consequence of disease progression in seven limbs (7/28, 25%), (3) residual veins in three limbs (3/28, 11%) mainly due to tactical errors (e.g. failure to strip the GSV), (4) complex patterns in 10 limbs (10/28, 36%). In the limbs with recurrence, 42 sources of venous reflux were identified: (1) 19 new sites of venous reflux were due to disease progression (15% of the operated limbs), (2) 13 were caused by neovascularisation (11.5% of the operated limbs), (3) six resulted from tactical failures (5.3% of the operated limbs) and (4) four were due to technical failures (3.5% of the operated limbs).

CONCLUSIONS

This study shows that the recurrence of varicose veins after surgery is not uncommon. However, the clinical condition of most affected limbs remains improved. Progression of the disease and neovascularisation are responsible for more than half of the recurrences. Rigorous evaluation of patients and assiduous surgical technique might reduce recurrence due to technical and tactical failures.

Primary Varicose Veins: Altered Transcription of VEGF and its Receptors (KDR, flt-1, Soluble flt-1) with Sapheno-femoral Junction Incompetence

OBJECTIVE

Loss of regulation of vascular endothelial growth factor (VEGF) production and action disturbs vascular homeostasis leading to pathology. Primary varicose veins (VVs) demonstrate aberrant production/release of VEGF. Our aim was to examine transcription of genes for VEGF (VEGF(121)/VEGF(165)) and its receptors (KDR, flt-1, s.flt-1) in VVs, in relation to underlying venous incompetence.

MATERIALS AND METHODS

Samples of varicose (n=83, 18 patients) or normal (n=14, five subjects) great saphenous vein were divided into segments, determined by anatomical position from the sapheno-femoral junction (SFJ). SFJ and segmental incompetence were determined from duplex scans. Gene transcripts were amplified by RT-PCR, analysed by scanning densitometry, and the levels of transcription determined by ratio to control gene GADPH-3 (GAP-3).

RESULTS

VEGF(121)/(165), KDR and flt-1 transcription was elevated in VVs overall (p<0.001), and in VVs with an incompetent SFJ (p<0.001), but not when the SFJ was functional; s.flt-1 was unaltered. Notably, gene transcription was unaffected by segmental position, or incompetence. Position below the SFJ correlated with increased transcription of s.flt-1 when the SFJ was incompetent (p<0.04), and s.flt-1 and VEGF(121) when the segment was incompetent (p<0.03).

CONCLUSIONS

SFJ incompetence is associated with altered transcription of VEGF and its receptors reflecting an aetiological mechanism or later stage of disease development. Altered VEGF(121) and s.flt-1 transcription may be an early event in varicogenesis.

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).