The impact of isolated lesser saphenous vein system incompetence on clinical signs and symptoms of chronic venous disease

Variations of the Saphenopopliteal Junction: An Ultrasonography Study in a Young Population, A Systematic Review and A Meta-Analysis

Saphenopopliteal junction classification has been developing, but still the precise knowledge of junction type is crucial for proper surgical treatment. We examined the saphenopopliteal junction by duplex venous scanning in 244 extremities in healthy volunteers (median age: 23.0 years, 83 females, 39 male) and performed a meta-analysis of 13 studies focusing on structural types of the junction. According to Schweighoffer's classification we distinguished 5 types of the junction and we subdivided type A according to Cavezzi's classification of gastrocnemial veins termination into two. We added type F (small saphenous vein-SSV terminates into popliteal vein-PV), described especially in cadaveric studies. In our study, the most frequent type was A1 (96 cases), followed by C (70), B (48), A2 (20), E (6), D (3) and F (0). The pooled prevalence estimate for types A + B + D + E was 54.7% (95% CI 40.9-69.6%) and for type C 24.4% (95% CI 19.3-29.5%), whereas in 17.1% (95% CI 6.3-27.9%) of cases, the SSV terminated in the PV with no cranial extension present. The knowledge of the saphenopopliteal junction and its variations prevalence can help clinicians to quickly identify the real type of the junction during routine examination. In mid-European population, the main type is A1 and worldwide type A.

The significance of minimally invasive treatment methods in the single-stage elimination of varicose vein disease of the great and small saphenous veins of the lower limbs and their branches

Introduction. This article presents a clinical case of successful and single-stage endovenous laser coagulation combined with miniphlebectomy in a patient with extensive and combined varicose lesion of all major subcutaneous veins of the lower limbs with significant symptoms of chronic venous insufficiency.

Aim. To determine the possibilities of simultaneous elimination of all main subcutaneous veins and their varicose tributaries on both lower limbs using minimally invasive methods.

Materials and methods. A 44-year-old female patient complained of gastrocnemius muscle cramps, swollen shins, feeling of heaviness at the end of the working day and the presence of varicose veins in both lower extremities. The severity of the chronic vein disease before the intervention according to the VCSS (Venous clinical Severity Score) was 8. As a result, patency of deep veins and condition of their valve apparatus, insufficiency of valves of the sapheno-femoral and sapheno-popliteal annexes on both sides with reflux through large and small saphenous veins and anterior accessory large saphenous vein on the right, insufficiency of perforating veins of both tibias were determined. Endovenous laser coagulation of the great and small saphenous veins on both sides and the right anterior accessory great saphenous vein, miniphlebectomy of dilated tributaries within both lower limbs was performed. The symptoms of chronic venous insufficiency decreased markedly. Swelling of the lower legs and cramps in the gastrocnemiu muscles have almost completely disappeared, and the feeling of heaviness in the legs after static loads has significantly decreased.

Conclusion. Endovenous laser coagulation with miniphlebectomy should be given preference in varicose vein disease with combined affection of all great saphenous veins of both lower limbs. Their application provides an opportunity to eliminate simultaneously incompetence of all target veins and to remove varicose dilated tributaries, providing good therapeutic and cosmetic effect without hospitalization and detachment of the patient from his or her work activity. 

Mini-invasive foam sclerotherapy-assisted ligation versus surgical flush ligation for incompetent sapheno-popliteal junction treatment

Objectives

Comparison of a flush sapheno-popliteal junction ligation versus a mini-invasive foam sclerotherapy-assisted ligation.

Methods

Forty-eight chronic venous disease patients underwent sapheno-popliteal junction flush ligation (group A). Forty-one patients underwent small saphenous vein ligation by means of mini-invasive incision with foam sclerotherapy of the popliteal stump (group B).

Results

At 4.1 ± 3.3 years mean follow-up, sapheno-popliteal junction recurrence was detected in four patients of group A (4/48; 8.3%) and in two cases of group B (3/41; 7.3%) ( P= ns). Mean procedural time was 36 ± 11 minutes versus 21 ± 6 minutes ( p<0.0001). A mild post-operative paresthesia lasting more than 24 h was reported in 6.3% (3/48) of group A versus 2.4% (1/41) ( p<0.009) of group B. At one-year check-up, Aberdeen Varicose Vein Questionnaire significantly improved in both groups with no significant difference between group A and B.

Conclusions

Foam-assisted mini-invasive sapheno-popliteal ligation represents a time and clinical-effective option, associated with a decrease in post-operative paresthesia risk.

Lack of symmetry in the major lower limb veins

BACKGROUND

Contemporary texts frequently present the venous system of the lower limb as a prime example of bilateral symmetry. However, overt bilateral asymmetry may be noted. This study was designed to examine and to quantify the level of symmetry in the lower extremity veins.

METHODS

This prospective cohort study evaluated major anatomic differences between right and left lower extremity veins in adult patients. Two hundred patients presenting with signs and symptoms of chronic venous disease (CVD; class 2-6) and venous reflux on duplex ultrasound were examined. A second group of 25 healthy volunteers without reflux or obstruction were used as controls. Those with conditions that could potentially alter vasculature, including vascular malformation, lower extremity trauma, and previously documented surgery for venous disease or bypass operations, were excluded. Only overt changes in the main superficial veins (great saphenous and small saphenous veins) and deep veins (femoral, popliteal, peroneal, and tibial veins) of the lower extremities were examined for symmetry. The level of small saphenous vein termination and thigh extension veins were also included. Location and extent of hypoplasia or aplasia and venous duplication or triplication were noted for all venous segments.

RESULTS

Of the 100 patients (200 limbs) with CVD class 2-3 (age, 49 years; range, 21-78 years), the extent of asymmetry in the superficial system, deep system, and combined was 84%, 86%, and 100%, respectively. Similarly, of the 100 patients (200 limbs) with CVD class 4-6 (age, 56 years; range, 28-84 years), the level of asymmetry in the superficial system, deep system, and combined was 83%, 84%, and 100%, respectively. Fifty (100 limbs) healthy volunteers (age, 46 years; range, 18-74 years) also presented similarly elevated levels of asymmetry compared with both cohorts of differing CVD class severity (superficial, 78%; deep, 84%; both, 100%). The most common reason for asymmetry in the great saphenous vein was hypoplasia or aplasia, whereas duplication was rare. In the small saphenous vein, the level of termination, thigh extension, and hypoplasia were the more frequent reasons. In the deep veins, duplication of the femoral and popliteal veins at different locations and extents was the most common finding for asymmetry. These findings remained consistent for all subgroups of patients and healthy controls.

CONCLUSIONS

A complete lack of symmetry is consistently seen in CVD patients and healthy subjects. Asymmetry in the veins of the lower extremities appears to be the norm. This is true despite examination of only overt changes and exclusion of multiple veins from the comparison.

Pathogenesis of Varicose Veins and Implications for Clinical Management

Varicose veins (VVs) classically result from venous hypertension owing to incompetence of the major communications between the superficial and deep veins of the lower extremity. In a significant number of patients, there is no demonstrable truncal saphenous reflux and varicosities are the result of isolated perforating and nonsaphenous vein incompetence. The clinical and histologic features of VVs are the result of disruption of the normal architectural structure of the venous wall as a consequence of remodeling of the extracellular matrix (ECM) in response to increased venous distention and altered hemodynamic shear stress. Although a number of genes, growth factors, proteases, and their inhibitors known to modulate the ECM have been implicated in the pathogenesis of VVs, their etiology remains unknown. The complex variations in venous anatomy in patients with VVs require detailed vein mapping to determine the source and drainage locations of reflux if the rates of residual and recurrent varicosities are to be reduced. The distinct pathogenic mechanisms involved in the development of VVs have important implications for the management of VVs that include a wide spectrum of treatment modalities ranging from reassurance, alternative medicines, conservative management or compression therapy, and surgical or endovascular therapy.

The Incidence, Clinical Importance and Management of Incompetent Gastrocnemius Vein

PURPOSE

To report the incidence, clinical importance and management of the incompetent gastrocnemius vein.

METHODS

The incompetency was examined by duplex and pulse-Doppler ultrasound at the popliteal fossa in a standing position between July 2006 and August 2014.

RESULTS

Among 1805 legs surveyed, 14 legs showed primary incompetent gastrocnemius vein (0.78%). The incompetency was in medial gastrocnemius vein in 13 legs (93%). Clinical manifestation was varicose vein in the small saphenous territory in nine, varicose vein in great saphenous territory in one, congestive dermatitis in two, calf clamp in one and no symptom in one. The nine cases with varicose vein in the small saphenous territory received surgical management. These included three cases with residual varicose veins after saphenopopliteal disconnection and stripping small saphenous vein. The root of the gastrocnemius vein was divided leaving no complication. In cases without varicose vein in small saphenous territory, an elastic compression socks was useful in some degree.

CONCLUSIONS

Incompetency of gastrocnemius vein was not so rare. When a case is accompanied by small saphenous varicose veins, division of the root of gastrocnemius vein along with small saphenous vein stripping is recommended in order to reduce residual varicose vein.

Quantification of superficial venous reflux by duplex ultrasound-role of reflux velocity in the assessment the clinical stage of chronic venous insufficiency

OBJECTIVES

This study we compare the duplex-derived parameters of reflux in patients with early and advanced superficial venous insufficiency (SVI) to identify parameters reflecting this.

METHODS

Two thousand and one hundred sixty limbs with primary reflux, categorized according to the CEAP (clinical, etiologic, anatomic and pathophysiologic) classification, and the patients were divided into two groups (group I [C1-3, Ep, As, Pr]; group II [C4-6, Ep, As, Pr]) were studied. The vein diameter, reflux duration(s), mean reflux velocity (MRV; cm/s), peak reflux velocity (PRV; cm/s), and total reflux volume (TRV; ml/s) were determined at the sapheno-femoral junction (SFJ), great saphenous vein (GSV) and sapheno-popliteal junction (SPJ).

RESULTS

Age and the proportion of males were greater in group II. MRV, PRV and TRV were greater in group II at the SFJ, SPJ and in GSV (p <0.01 for all), although the duration of SPJ reflux was non-discriminatory (p = 0.78). From receiver operating characteristic (ROC) curve, optimal cut-off points of 27.8, 47.8, and 36.2 cm/s for the PRV at the SFJ (p <0.01), GSV (p <0.01), and SPJ (p <0.01) discriminated between the two groups.

CONCLUSION

PRV and MRV improved discrimination between early and advanced SVI compared to reflux duration.

Targeted endovenous treatment of Giacomini vein insufficiency-associated varicose disease: considering the reflux patterns

PURPOSE

We aimed to assess the technical feasibility of targeted endovenous treatment of Giacomini vein insufficiency (GVI)-associated varicose disease and report our early results.

METHODS

We retrospectively screened 335 patients with varicose disease who underwent endovenous laser ablation from September 2011 to January 2013, and determined 17 patients who underwent Giacomini vein ablation. Using a targeted endovenous treatment approach considering the reflux pattern, all healthy great saphenous veins (GSV) or vein segments were preserved while all insufficient veins (Giacomini vein, perforator veins, small saphenous vein, anterior accessory GSV, major tributary veins, or incompetent segments of the GSV) were ablated. Treatment success was analysed using Doppler findings and clinical assessment scores before and after treatment.

RESULTS

Targeted endovenous treatment was technically successful in all cases. Seven GSVs were preserved totally and three GSVs were preserved partially (10/17, 58%), with no major complications. Clinical assessment scores and Doppler findings were improved in all cases.

CONCLUSION

Targeted endovenous treatment of GVI-associated varicose disease is safe and effective. In majority of GVI cases saphenous vein can be preserved using this approach.

Endovenous laser ablation versus conventional surgery in the treatment of small saphenous vein incompetence

INTRODUCTION

In this multicenter, randomized controlled trial, endovenous laser ablation (EVLA) is compared with conventional surgery for the treatment of varicose veins based on incompetence of the small saphenous vein and the saphenopopliteal junction (SPJ).

METHODS

In two Dutch hospitals, 189 patients were enrolled and randomized to receive EVLA (810-nm laser) or ligation of the SPJ. End points were success rate measured with duplex ultrasound (6 weeks post-treatment), perioperative pain, quality of life, duration of surgery, difficulty of surgery, complications, cosmetic results, and number of days to resume work and normal activities. Pain was measured on a visual analog scale (VAS). Quality of life was assessed using the Aberdeen Varicose Vein Questionnaire (AVVQ) and Euro Qol-5D. The follow-up duration in this article is 6 weeks.

RESULTS

One hundred seventy-five patients have been treated and analyzed. One hundred eighteen patients (67%) underwent EVLA, and 57 patients (33%) underwent ligation of the SPJ. The patient characteristics were similar in both groups. In the surgery group, 21% residual incompetence of the SPJ was seen after 6 weeks, compared with 0.9% in the laser group. Both treatment modalities reduced pain after 6 weeks. One week post-treatment, patients in the EVLA group temporarily experienced more pain compared with the surgery group (31 vs 18 on a VAS from 0 to 100). There were no significant differences between the two groups with respect to quality of life. Both treatments did show improvement in quality of life. Also with regard to the cosmetics, there were no differences, aside from the fact that patients rated their scar as more beautiful after EVLA. After EVLA, patients could return to work more quickly. The operation time was longer in the surgery group. After 2 weeks, there were significantly more neurological complications in the surgery group: 18 (31%) vs 16 (17%) patients in the EVLA group. Ten percent of patients in the surgery group developed a surgical site infection vs 0% in the EVLA group.

CONCLUSIONS

EVLA provides an excellent alternative to conventional surgery in the treatment of symptomatic varicose veins due to an incompetent small saphenous vein with SPJ. EVLA has a superior immediate success rate, is easier and faster, and has fewer complications.

Endovenous laser ablation and sclerotherapy for incompetent vein of Giacomini

PURPOSE

To retrospectively evaluate the feasibility and effectiveness of endovenous laser ablation or ultrasound-guided foam sclerotherapy for Giacomini vein insufficiency. This is the largest cohort of patients treated for Giacomini vein insufficiency with endovenous laser ablation or ultrasound-guided foam sclerotherapy.

MATERIAL AND METHODS

Over a three-year period, 23 females and nine males (age range, 19-67 years) treated for Giacomini vein insufficiency with or without saphenous vein insufficiency were retrospectively reviewed. Diagnosis of venous insufficiency was made by color Doppler ultrasonography. Symptomatic insufficiency of the Giacomini vein or the saphenous veins was treated with endovenous laser ablation. Ultrasound-guided foam sclerotherapy was used for tortuous incompetent Giacomini veins. The venous disease was categorized according to the clinical, etiological, anatomical, and pathological classification, and clinical severity was graded with the venous clinical severity score. Follow-up included clinical examination and color Doppler ultrasonography.

RESULTS

Thirty-nine limbs in 32 patients were treated (25 endovenous laser ablation and seven ultrasound-guided foam sclerotherapy). All procedures were technically successful. One patient in the ultrasound-guided foam sclerotherapy group had a recurrence with successful repeated treatment. Recurrence was not seen in the endovenous laser ablation group. No complications were observed. All patients had resolution and improvement in 100% of their symptoms at 12 months of follow-up.

CONCLUSION

Giacomini vein insufficiency is mostly seen with insufficiency of the great saphenous vein and can be effectively treated with endovenous laser ablation or ultrasound-guided foam sclerotherapy.

Reflux patterns and risk factors of primary varicose veins’ clinical severity

Objectives

Primarily, to determine the association between the clinical severity of primary varicose veins and different reflux patterns in an anatomic and haemodynamic clinical study using duplex ultrasonography (DU). Secondly, to analyse the association of clinical severity with other aspects, such as risk factors for chronic venous insufficiency (CVI) and other concurrent diseases.

Method

A total of 2036 limbs were evaluated using DU. Clinical status was characterized by the CEAP (clinical, aetiological, anatomical and pathological elements) classification. The degree of clinical severity was grouped into two categories, mild to moderate CVI (C1–C3) and severe CVI, characterized by the presence of skin changes (C4–C6). We analysed the association of the different reflux patterns with CEAP status.

Results

Saphenofemoral junction (SFJ) reflux of the great saphenous vein (GSV) was associated with the most severe form of the disease (odds ratio [OR] = 2.96; confidence interval [CI] 95%: 2.2–3.8), whereas competent SFJ of the GSV with reflux from proximal veins (OR = 2; CI 95%: 1.4 –2.7) and the pure non-saphenous reflux (OR = 4.1; CI 95%: 1.8–9.0) were associated with mild to moderate CVI. Obesity increased the frequency of severe CVI 2.7 times (OR = 2.7; CI 95%: 1.6–4.6); being a woman also increased the frequency of more severe disease 1.3 times (OR = 1.3; CI 95%: 1.0–1.7).

Conclusion

Anatomical and haemodynamic studies by DU are postulated as a useful diagnostic tool that allow, by identifying the pattern of venous reflux of varicose pathology, characterization of the probable association to CVI clinical severity.

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.

Diagnosis and follow-up of varicose veins with duplex ultrasound: how and why?

Chronic venous disease (CVD) is very prevalent and causes a significant financial burden in Western societies. Accurate diagnosis is mandatory to define the anatomy and pathophysiology involved in the disease process. Duplex ultrasound (DU) is a well-established non-invasive tool used for varicose veins work-up that, most recently, has also been utilized for follow-up after endovenous procedures such as endovenous laser or radiofrequency ablation and foam sclerotherapy. Insightful information on how DU is performed during varicose veins work-up and the rationale of DU utilization for endovenous procedures are discussed.

Results of Radiofrequency Ablation of the Small Saphenous Vein in the Supine Position

Objectives: To report the results of a novel approach using supine positioning for radiofrequency ablation (RFA) of the small saphenous vein (SSV) with combined ablation of the great saphenous vein (GSV). Methods: Over a 24-month period, we identified patients with symptomatic SSV incompetence. Access to the SSV was accomplished by ultrasound-guided venipuncture with the patient in the supine position. Results: Small saphenous vein ablation was performed on 27 limbs in 26 patients. Median follow-up was 94 days (interquartile range [IQR] 26, 171). Mean clinical–etiologic–anatomic–pathophysiologic (CEAP) score was 3.5 ± 1.3. Small saphenous vein ablation was performed in conjunction with GSV ablation in 17 patients and with phlebectomy in 14 patients. Postoperative ultrasound was performed after 26 of 27 procedures. The SSV was sealed in all 26 cases. Two patients (8%) had a deep venous thrombosis (DVT). Conclusions: The SSV can be effectively sealed by RFA from the supine position and combined SSV/GSV ablation can be carried out in a single setting.

Early results of endovenous ablation with a 980-nm diode laser for an incompetent vein of Giacomini

OBJECTIVE

We wanted to evaluate the effectiveness of endovenous ablation of the incompetent vein of Giacomini using a 980-nm diode laser.

MATERIALS AND METHODS

A total of 18 patients (18 limbs, 4%) had the incompetent vein of Giacomini. Retrograde reflux originating from the great saphenous vein was noted in sixteen limbs and paradoxical diastolic anterograde reflux from the saphenopopliteal junction was observed in two limbs. After tumescent anesthesia, laser ablation using a 980-nm wavelength laser fiber was performed under ultrasound and/or fluoroscopic guidance. Patients were evaluated clinically and with duplex ultrasound at one week and at one, three, six and twelve months after laser ablation for the technical and clinical success.

RESULTS

In the 18 limbs, the technical success rate was 100%. Continued closure of the vein of Giacomini was seen in 18 of 18 limbs after one month, in 12 of 12 limbs after three and six months and in six of six limbs after twelve months. No recanalization of the vein and no major complications occurred.

CONCLUSION

Endovenous laser ablation with a 980-nm wavelength is an effective and safe procedure for treating an incompetent vein of Giacomini.

Conventional surgery and endovenous laser ablation of recurrent varicose veins of the small saphenous vein: a retrospective clinical comparison and assessment of patient satisfaction

Objectives

Recurrences of varicosities of the small saphenous vein (SSV) are common. Surgical reintervention is associated with increased complication rates. The aim of the study was to assess the feasibility of endovenous laser ablation (EVLA) in recurrent varicose veins of the SSV and to compare this technique with surgical reintervention.

Methods

All case files of patients treated for SSV varicosities between May 2006 and October 2008 were evaluated and recurrences were selected. Demographics, duplex findings, clinical, aetiological, anatomical and pathological classification, perioperative and follow-up data were all registered. Additionally, a questionnaire focusing on patient satisfaction was taken.

Results

Two hundred and eighty-one patients were treated for varicosities of the SSV, of which 42 were for recurrences. Twenty-six of these were treated with EVLA, all under local anaesthesia, and 16 were surgically treated. Most surgically treated patients were treated under regional anaesthesia (88%). Technical success was achieved in 94% of surgically treated patients and in all EVLA-treated patients. Complications in both groups were mostly minor and self-limiting. Sural nerve neuralgia appeared to be more frequent in the surgically treated group (20% versus 9%). After correction for length of follow-up, the incidence of rerecurrences was not statistically significant between groups.

Conclusion

EVLA is feasible in patients with recurrent varicose veins of the SSV with possibly a lower incidence of sural nerve injury. Patient satisfaction is high for both treatment modalities. Studies with larger samples are indicated to confirm these observations.

Short saphenous vein incompetence and chronic lower extremity venous disease

OBJECTIVE

We performed this prospective study on patients with signs and symptoms of chronic venous disease to emphasize short saphenous vein (SSV) insufficiency, which is not routinely evaluated with Doppler ultrasonography in every center.

METHODS

One hundred seventy-eight patients with signs and symptoms of chronic venous disease were included in the study. We used the CEAP (clinical, etiologic, anatomic, and pathophysiologic data) classification in evaluation of the limbs with isolated and nonisolated SSV incompetence. Patients were classified according to age, occupation, body mass index, and associated chronic illness. A chi(2) test and a t test were used in the statistical analysis.

RESULTS

Reflux was observed in 190 (53%) of 356 limbs. In 11 limbs, isolated SSV reflux was observed. These 11 limbs were classified as CEAP grade 2 (3 limbs), CEAP grade 3 (3 limbs), and CEAP grade 4 (5 limbs). Short saphenous vein reflux was observed in 21 (5.9%) of 356 limbs. Mean SSV diameters were 3.89 mm (range, 1-11 mm) on the right and 4.03 mm (1.3-10 mm) on the left.

CONCLUSIONS

No statistical significance was found between age, sex, body mass index, occupation, and associated chronic disease and deep or superficial venous system incompetence. A statistically significant difference was found between the SSV diameter of the limbs and associated venous incompetence.

The nonsaphenous vein of the popliteal fossa: Prevalence, patterns of reflux, hemodynamic quantification, and clinical significance

BACKGROUND

A large tortuous vein coursing over the posterior aspect of the knee and the upper calf may give rise to a constellation of varicose veins unrelated to the great (GSV) or small (SSV) saphenous veins. Designated the popliteal fossa vein (PFV), it perforates the deep popliteal fascia and empties into the deep system. We examined the prevalence, anatomic reflux patterns, hemodynamic role, and clinical significance of the PFV.

METHODS

We examined 543 patients (818 limbs) with venous disease, aged 14 to 94 years (median, 55 years). The study consisted of group A, comprising limbs with a PFV, and group B, formed by the remaining limbs. The history, clinical examination, and venous duplex scan findings were analyzed retrospectively. Venous clinical severity and venous segmental disease scores of group A were compared with those of an equal number of CEAP-, sex-, and age-matched control limbs. In situ venous hemodynamics of the PFV obtained with duplex scan are reported.

RESULTS

A PFV was found in 24 (2.93%) of 818 limbs (95% confidence interval [CI], 1.8%-4.1%); 24 (4.4%) of 543 subjects (95% CI, 2.7%-6.2%), 12 men and 12 women aged 23 to 82 years (median, 54 years) had a PFV. CEAP clinical classes in limbs with a PFV were as follows: C2, 15 limbs; C3, 5 limbs; C4, 2 limbs; C5, 1 limb; and C6, 1 limb. Proximal and distal (92%), superficial (100%), perforator (87.5%), and complex-pattern (41.7%) reflux occurred more often in group A (P < .01). Incompetence in the GSV (75%), posterior arch, and posteromedial and saphenous tributaries was also more frequent in group A (P < .05). SSV reflux in group A (29%) matched that in group B. The PFV terminated at the deep system (96% in the popliteal vein) above the SSV (median distance, 1.5 cm; 95% CI, 0.5-2 cm). The odds ratio for a PFV in limbs with prior SSV disconnection was 5.68. Deep reflux was evenly distributed in group A (41.7%) and group B (27%). The prevalence of incompetent perforators was 283% (95% CI, 194%-373%) in group A and 96% (95% CI, 95%-98%) in group B (P < .001). PFV tributaries were distributed at the popliteal area (100%); the posterior (87.5%), medial (62.5%), and lateral (37.5%) upper calf; and the posterior distal thigh (17%), often projecting to the posterior GSV arch (50%). The (median) peak velocity of reflux in the PFV was 82.6 cm/s, the mean velocity was 17.7 cm/s, the duration was 2.4 seconds, the volume flow was 231.5 mL/min, and the expelled volume was 9.3 mL. The median diameter of the PFV at the crossing of the fascia was 0.527 cm. Venous clinical severity (range, 2-17; median, 5.5) and venous segmental disease (range, 0.5-8; median, 2.75) scores in limbs with a PFV exceeded (P <or= .04) those of the control limbs.

CONCLUSIONS

With a prevalence of 4.4%, the PFV presents in limbs featuring complex reflux patterns involving all three venous systems proximally and distally. Limbs with a PFV have a higher propensity for GSV and superficial tributary reflux and have perforator vein incompetence three times more often than limbs without this vein. The PFV perforates the deep popliteal fascia terminating at the deep system (ie, the popliteal vein in 96%) distinctly above the SSV. In light of its reflux dynamics, nearing or exceeding those of severely impaired perforator veins, and the complex patterns of reflux (venous segmental disease) and venous clinical severity (high venous clinical severity scores) of the affected limbs, clinical and investigational awareness of the PFV is warranted.

Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower Limbs—UIP Consensus Document. Part II. Anatomy

OBJECTIVES

Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP), The aim was to obtain a consensus of international experts on the methodology to be used for assessment of anatomy of superficial and perforating veins in the lower limb by ultrasound imaging.

DESIGN

Consensus conference leading to a consensus document.

METHODS

The authors performed a systematic review of the published literature on duplex anatomy of the superficial and perforating veins of the lower limbs; afterwards they invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the authors and the experts (text and images) were made available to all participants via the UIP website. The authors prepared a draft document for discussion at the UIP Chapter meeting held in San Diego, USA in August 2003. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually, all participants agreed the final version of the paper.

RESULTS

The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document provides a detailed methodology for complete ultrasound assessment of the anatomy of the superficial and perforating veins in the lower limbs.

CONCLUSIONS

The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs venous system by duplex ultrasonography, with specific reference to the anatomy of the main superficial veins and perforators of the lower limbs in healthy and varicose subjects.

Prevalência do refluxo na veia safena parva em varizes primárias não complicadas dos membros inferiores pelo eco-Doppler colorido

OBJETIVO: Determinar a prevalência de refluxo venoso na veia safena parva em membros inferiores com varizes primárias não complicadas pelo eco-Doppler colorido. MÉTODO: No período de 18 meses, 1.953 pacientes foram submetidos ao eco-Doppler colorido de membros inferiores por doença venosa. Destes, 1.631 com varizes primárias não complicadas foram selecionados para esta análise, sendo que 1.383 eram do sexo feminino (84,79%) e 248 (15,21%) do sexo masculino. A média de idade dos pacientes foi de 42,89 (± 0,48) anos, variando de 13 a 85 anos. Dos 1.631 pacientes, 1.323 foram submetidos a exame bilateral e 308 a exame unilateral, totalizando 2.954 membros inferiores com varizes primárias não complicadas avaliados. Desse total, 1.461 eram membros inferiores direitos e 1.493, esquerdos. Todos os exames foram realizados seguindo o mesmo protocolo. RESULTADO: Dos 2.954 membros inferiores avaliados, 372 (12,59%) apresentaram refluxo em veia safena parva. A prevalência nos homens foi de 14,08% e, nas mulheres, de 12,35%. O refluxo da safena parva foi maior no membro inferior esquerdo (13.13%) do que no direito (12,05%). A prevalência do refluxo foi significativamente maior nos pacientes acima de 60 anos. CONCLUSÃO: O refluxo da veia safena parva é relativamente comum, e sua pesquisa deve ser sempre realizada em pacientes com varizes primárias de membros inferiores.

Sonography for Deep Venous Thrombosis

Deep venous thrombosis (DVT) is a one of the most common problems facing the clinician in medicine today. It is often asymptomatic and goes undiagnosed with potentially fatal consequences. Ultrasound has become the "gold standard" in the diagnosis of deep venous thrombosis and with proper attention to technique sensitivity of this test is approximately 97%. An understanding of anatomy, pathophysiology, and risk factors is important. Thrombus formation usually begins beneath a valve leaflet below the knee. Approximately 40% will resolve spontaneously, 40% will become organized, and 20% will propagate. Whether or not a calf vein thrombus is identified, a repeat examination in 7 to 10 days is recommended in patients with risk factors or when deep venous thrombosis is suspected. The three main risk factors for thrombus formation are age greater than 75 years, previous history of deep venous thrombosis, and underlying malignancy. Other diagnostic studies include the contrast venogram, CT or MRI venogram, Tc99m Apcitide study, and the laboratory test D-Dimer. The D-Dimer study is being used more frequently as a screening test with 99% sensitivity in detecting thrombus, whether deep venous thrombosis or pulmonary embolism. However, specificity is only approximately 50% with many conditions leading to false-positive exams. Therefore, a negative examination is useful in avoiding other diagnostic studies, but a positive one may be misleading. Conditions that can lead to a false-positive examination include, but are not limited to diabetes, pregnancy, liver disease, heart conditions, recent surgery, and some gastrointestinal diseases. Like the sonogram, two negative D-Dimer studies a week apart exclude the diagnosis of deep venous thrombosis. Compression sonography with color Doppler remains the best overall test for deep venous thrombosis. It is easy to perform, less expensive than most "high tech" studies, can be performed as a portable examination, and is highly reliable when done properly.

[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.

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.

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.

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.

The impact of duplex scanning in phlebology

Chronic venous disease (CVD) is a tremendous medical and economic burden on society. In the past two decades the use of duplex ultrasound has emerged as the diagnostic method of choice for the diagnosis and management of CVD. In this article, we describe the specific techniques used in the assessment of the superficial, perforating, and deep venous systems. We also discuss the methods of ulcer bed and chronic obstruction evaluation. The contributions of the duplex ultrasound to the understanding of the pathophysiology and improvement of treatments for chronic venous disease are reviewed.

Fascial relationships of the short saphenous vein

OBJECTIVES

The purpose of this study was to define the relationships between the short saphenous vein (SSV) and the fasciae of the leg, including the muscular fascia (MF) and the membranous layer (ML) of the subcutaneous tissue.

METHODS

Fascial relationships of the SSV were evaluated by means of dissection in 30 cadaveric limbs and by means of duplex sonography in 270 healthy limbs from living subjects.

RESULTS

All along the leg, the SSV courses in a flat compartment delimited by the MF and the ML. Neither results from dissection nor results from sonographic examination demonstrated piercing of the MF by the SSV. A hyperechoic lamina similar to a ligament connects the SSV to the fasciae by which it is encased. An SSV tributary and collateral vessels course out of this space and are devoid of any fascial wrapping.

CONCLUSIONS

The SSV does not correspond to the classical description of a "superficial" vein. In fact, from the anatomical point of view, the SSV is an interfascial vein, because it is encased by two connective fasciae, just like the greater saphenous vein. Fascial relationships of the SSV suggest that muscular contraction potentially influences the caliber and hemodynamics of the SSV. In addition, the ML is arranged as a sort of mechanical shield that could counteract dilative pathologic conditions in varicose limbs.