Comparative study of different venous reflux duplex quantitation parameters

Improvements of deep vein reflux following radiofrequency ablation for saphenous vein incompetence

Objectives

The aim of this study was to describe the changes of deep vein reflux after radiofrequency ablation for great saphenous vein incompetence.

Method

The data on 139 limbs which were treated with radiofrequency ablation for great saphenous vein incompetence were prospectively collected and reviewed.

Results

Deep vein reflux was present in 43 of 139 limbs (30.9%). There were no significant differences in the rate of successful closure, the incidence of procedure-related complications, and the improvements of symptoms and quality of life between the limbs with or without deep vein reflux. With a mean follow-up of 5.9 months, the peak reflux velocity and duration of reflux were improved in all limbs with deep vein reflux and it was completely corrected in 13 limbs (30.2%) after radiofrequency ablation.

Conclusions

The presence of deep vein reflux does not affect the treatment outcomes of radiofrequency ablation for great saphenous vein incompetence and is improved in all patients. Deep vein reflux is not a barrier to performing radiofrequency ablation.

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.

Venous Reflux and Venous Distensibility in Varicose and Healthy Veins

OBJECTIVES

The aim of this study was to analyse venous diameter changes and venous reflux parameters, assessed during a standardised Valsalva manoeuvre in healthy subjects and in patients with varicose veins.

METHODS

Measurements were carried out in 444 vein segments, (96 legs of 48 healthy volunteers, 52 legs of 35 patients with varicose veins). The common femoral vein (CVF), the femoral vein (FV) and the great saphenous vein (GSV) were investigated. The parameters of reflux and the relative venous diameter change (VD diff %) were measured simultaneously during a standardised Valsalva manoeuvre.

RESULTS

Venous diameter changes during Valsalva manoeuvre (VD diff) were significantly greater in the GSV and in the deep veins of varicose patients compared to healthy subjects. The median (Interquartile range) of VD max in the CFV was: 13.1 (3.5) mm and 11.2 (3.4) mm (p=0.0002, Mann-Whitney - U test), in the FV 7.8 (2.7) mm and 6.9 (2.0) mm (p=0.01, Mann-Whitney), in the GSV: 7.3 (3.7) mm and 4.2 (1.1) mm (p<0.0001, Mann-Whitney) for the varicose and healthy veins respectively. Good correlation was seen for the retrograde peak reflux velocity (PRV) and VD diff % in varicose veins (r=0.71 (0.57 - 0.81) p<0.0001, Mann-Whitney).

CONCLUSION

Relative venous diameter--changes during a standardised Valsalva manoeuvre are significantly larger in the deep and superficial veins of varicose vein patients compared with healthy veins, the increased distensibility correlates with venous reflux parameters in varicose vein patients.

Hemodynamic and clinical impact of ultrasound-derived venous reflux parameters

PURPOSE

This study was undertaken to assess which ultrasound-derived parameter was superior for measuring venous reflux quantitatively and to evaluate the importance of popliteal vein valve reflux.

PATIENTS AND METHODS

A retrospective analysis was performed of 244 refluxive limbs in 182 patients who underwent ultrasound scanning, venous pressure measurement, air plethysmography, and clinical classification of severity according to the CEAP score. Reflux time (RT, s), peak reflux velocity (PRV, m/s), time of average rate of reflux (TAF, mL/min), absolute displaced volume retrogradely (ADV, mL) were compared to clinical class, ambulatory venous pressure (% drop), venous filling time (s), and venous filling index (mL/s) using nonparametric statistical tests. A P value of <.05 was considered significant. Limbs were divided into 3 groups: (A) axial great saphenous vein reflux only (n = 68); (B) axial deep reflux including popliteal vein incompetence with or without concomitant gastrocnemius or great or small saphenous vein reflux (all ultrasound reflux parameters of each refluxive vein added at the knee level) (n = 79); and (C) all limbs with popliteal vein reflux (the ultrasound data of the refluxive popliteal vein exclusively was used in comparison regardless of concomitant associated reflux) (n = 103). Limbs were also stratified into limbs with skin changes and ulcer (C-class 4-6) and those without (C-class 1-3) and subsequently compared.

RESULTS

No meaningful significant correlation was found between RT and the clinical and hemodynamic results in groups A and B. The PRV and TAF correlated significantly with the hemodynamic parameters. The PRV and TAF and clinical severity trended towards correlation in group A (P =.0554 and P =.0998, respectively), but was significantly correlated in group B. The poor hemodynamic condition in the subset of C-class 4-6 limbs in groups A and B was reflected in a greater PRV, TAF, and ADV in this subset as compared with the limbs in C-class 1-3. RT was not significantly different in the subsets of limbs, further suggesting that RT is not related to hemodynamic or clinical state of the limbs. No meaningful correlations were found in group C. Although the hemodynamic data were significantly poorer in the subset of limbs with C-class 4-6 than in C-class 1-3, the ultrasound-derived parameters were not significantly different.

CONCLUSION

The duration of valve reflux time (or valve closure time) cannot be used to quantify severity of reflux and is purely a qualitative measurement. The PRV and the rate of reflux appeared to better reflect the magnitude of venous incompetence. In the presence of axial reflux, it appeared logical and physiologically correct to sum up these reflux parameters for each venous segment crossing the knee. The popliteal valve reflux (the "gatekeeper" function) was not in itself an important determinant of venous hemodynamics and clinical severity. Additional reflux in other venous segments must be taken into account.

Deep axial reflux, an important contributor to skin changes or ulcer in chronic venous disease

OBJECTIVE

We undertook this cross-sectional study to investigate the distribution of venous reflux and effect of axial reflux in superficial and deep veins and to determine the clinical value of quantifying peak reverse flow velocity and reflux time in limbs with chronic venous disease.

PATIENTS AND METHODS

Four hundred one legs (127 with skin changes, 274 without skin changes) in 272 patients were examined with duplex ultrasound scanning, and peak reverse flow velocity and reflux time were measured. Both parameters were graded on a scale of 0 to 4. The sum of reverse flow scores was calculated from seven venous segments, three in superficial veins (great saphenous vein at saphenofemoral junction, great saphenous vein below knee, small saphenous vein) and four in deep veins (common femoral vein, femoral vein, deep femoral vein, popliteal vein). Axial reflux was defined as reflux in the great saphenous vein above and below the knee or in the femoral vein to the popliteal vein below the knee. Reflux parameters and presence or absence of axial reflux in superficial or deep veins were correlated with prevalence of skin changes or ulcer (CEAP class 4-6).

RESULTS

The most common anatomic presentation was incompetence in all three systems (superficial, deep, perforator; 46%) or in superficial or perforator veins (28%). Isolated reflux in one system only was rare (15%; superficial, 28 legs; deep, 14 legs; perforator, 18 legs). Deep venous incompetence was present in 244 legs (61%). If common femoral vein reflux was excluded, prevalence of deep venous incompetence was 52%. The cause, according to findings at duplex ultrasound scanning, was primary in 302 legs (75%) and secondary in 99 legs (25%). Presence of axial deep venous reflux increased significantly with prevalence of skin changes or ulcer (C4-C6; odds ratio [OR], 2.7; 95% confidence interval [CI], 1.56-4.67). Of 110 extremities with incompetent popliteal vein, 81 legs had even femoral vein reflux, with significantly more skin changes or ulcer, compared with 29 legs with popliteal reflux alone (P =.025). Legs with skin changes or ulcer had significantly higher total peak reverse flow velocity (P =.006), but the difference for total reflux time did not reach significance (P =.084) compared with legs without skin changes. In contrast, presence of axial reflux in superficial veins did not increase prevalence of skin changes (OR, 0.73; 95% CI, 0.44-1.2). Incompetent perforator veins were observed as often in patients with no skin changes (C0-C3, 215 of 274, 78%) as in patients with skin changes (C4-C6, 106 of 127, 83%; P =.25).

CONCLUSION

Continuous axial deep venous reflux is a major contributor to increased prevalence of skin changes or ulcer in patients with chronic venous disease compared with segmental deep venous reflux above or below the knee only. The total peak reverse flow velocity score is significantly higher in patients with skin changes or ulcer. It is questionable whether peak reverse flow velocity and reflux time can be used to quantify venous reflux; however, if they are used, peak reverse flow velocity seems to reflect venous malfunction more appropriately.

Comparative evaluation of duplex-derived parameters in patients with chronic venous insufficiency: correlation with clinical manifestations

BACKGROUND

Quantification of venous reflux is still a matter of debate. Our goal was to compare the duplex-derived parameters between patients with early and advanced chronic venous insufficiency (CVI), and to determine indicative parameters reflecting the progression of CVI.

STUDY DESIGN

A total of 1,132 limbs in 914 patients with primary valvular incompetence were included. Clinical manifestations were categorized according to the CEAP (clinical, etiologic, anatomic, and pathophysiologic) classification, and the patients were divided into two groups: group I (those with relatively early CVI, C(1-3)E(P),A(S,D,P),P(R)) and group II (those with advanced CVI, C(4-6)E(P),A(S,D,P),P(R)). The distribution of venous insufficiency was determined, and the parameters assessed were the duration of reflux (s), the peak reflux velocity (cm/s), and the flow at peak reflux (mL/s).

RESULTS

There was no notable difference in overall superficial venous reflux between the groups, and the frequency of isolated deep and perforator incompetence did not differ between the groups. The duration of reflux did not improve the discrimination power between the groups. In contrast, the peak reflux velocity had significant discrimination power at the saphenofemoral junction (p < 0.0001), the saphenopopliteal junction (p = 0.0002), in the greater saphenous vein (p < 0.0001), in the superficial femoral vein (p = 0.0041), and in the popliteal vein (p = 0.003). The peak reflux flow was significantly higher in group II at the saphenofemoral junction (p < 0.0001), the saphenopopliteal junction (p = 0.0029), in the greater saphenous vein (p < 0.0001), in the common femoral vein (p = 0.006), in the superficial femoral vein (p = 0.0005), and in the popliteal vein (p = 0.0003).

CONCLUSIONS

Superficial venous insufficiency might play a major role in the development of advanced CVI. The peak reflux velocity and peak reflux volume improve discrimination power between early-stage and advanced CVI.

The mechanism of venous valve closure in normal physiologic conditions

PURPOSE

The purpose of this investigation was to study the mechanism of venous valve closure in physiologic conditions in situ, particularly the clarification of the role of reversed flow through the valve in the closure of the valve cusps. A second purpose was the study of temporal relations between movements of the valve cusps, changes in geometry of venous sinus, and blood flow.

METHODS

Twelve healthy volunteers underwent examination with duplex ultrasound scanning. The time relationship between the flow and venous valve movements was analyzed on the basis of real time ultrasound scan records of the saphenofemoral junction. The size and shape of the common femoral vein and the proximal greater saphenous vein were measured with a planimeter.

RESULTS

Reverse flow below the valve was registered in only one of the 12 studied subjects. The maximum peak velocity of the reverse flow in this case was 0.8 cm/s and the duration was 0.2 seconds. The reverse flow was registered just before and just after valve closure. The mean duration of the outflow wave below the valve was 816 +/- 57 ms, which was not significantly different from the time of the valve cycle (819 +/- 55 ms; P =.864). The closure of the valve coincided with the decrease of the flow velocities. The first detectable movement of the valve cusps occurred 108 +/- 21 ms after the beginning of the flow deceleration. The mean time interval from the first cusp movement to the complete closure of the valve was 139 +/- 51 ms. Both the size and the shape of the sinus changed during the valve cycle. The size of the sinus increased as much as 127% of the baseline value (1.79 +/- 0.25 cm at baseline; 2.27 +/- 0.23 cm maximum; P =.02), and it became more spheric in shape. The changes in size and shape of the sinus coincided with the movements of the valve cusps. The first detectable change in the sinus size occurred 80 +/- 30 ms after the first detectable movement of the cusps toward closure.

CONCLUSION

Reverse flow through the valve is not necessary for the closure of the venous valve. The closure of the venous valve coincides with the decrease of the flow velocities and the ballooning of the sinus (increase of size and the curvature of the valve sinus).