Clinical Significance of Ostial Great Saphenous Vein Reflux

Eur J Vasc Endovasc Surg 31, 320–324 (2006) doi:10.1016/j.ejvs.2005.08.017, available online at http://www.sciencedirect.com on

Clinical Significance of Ostial Great Saphenous Vein Reflux M.V.L. Barros,1* N. Labropoulos,2 A.L.P. Ribeiro,3 R.Y. Okawa 1,4 and F.S. Machado 1 1

Ecoar-Noninvasive Diagnostic Medicine, Brazil, 2Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA, 3Department of Internal Medicine, and 4Post-Graduation Course in Surgery, UFMG (Federal University of Minas Gerais), Belo Horizonte, Brazil

Purpose. To evaluate anatomical and haemodynamic differences in patients with great saphenous vein (GSV) insufficiency by duplex scanning and air plethysmography. Material and methods. Duplex scanning and air plethysmography examination were undertaken. One hundred and twenty-one limbs in 91 patients were selected prospectively and divided into three groups: group A consisted of 27 controls; group B consisted of 25 limbs with GSV reflux and normal saphenous femoral junction (SFJ) and group C consisted of 69 limbs of patients with GSV and SFJ reflux. The presence of reflux and GSV diameter (SFJ, proximal and medial thirds of the thigh, the knee and medial and distal thirds of the calf) were assessed by duplex scanning. Air plethysmography was used to evaluate haemodynamic parameters: total venous volume (VV), venous filling index (VFI), residual volume fraction (RVF) and ejection fraction (EF). Results. There was a significant difference in GSV diameter among the three groups in almost all segments evaluated (e.g. medial thigh group AZ2.4 SD 0.3 mm; BZ3.2 SD 0.7 mm; CZ5.9 SD 2.2 mm p!0.001, Anova). A significant difference in VFI was found among the groups (group AZ1.2 SD 0.5; BZ2.0 SD 1.4; CZ4.0 SD 2.5 p!0.05, Anova). VV was statistical different between groups A and C (pZ0.004) and B and C(pZ0.03). EF and RVF were comparable in all groups. The VFI was normal in 68% in group B comparing with only 14.5% in group C patients, finding a reflux more than 5 ml/s (determined by VFI) in 26.1% of the group C patients, comparing with only 4% of group B patients (p!0.05). Conclusion. We have shown that in patients with GSV reflux those with incompetence of the ostial valve of the GSV show greater venous reflux and dilatation of the saphenous trunk than those in whom the ostial valve is competent. Keywords: Great saphenous vein; Air plethysmography; Duplex scanning.

Introduction Assessment of greater saphenous vein (GSV) insufficiency is an important component of the management of patients with varicose vein disease.1 The surgical approach to GSV incompetence has been changed over the years and there has been a number of recent publications suggesting that surgery should be designed to preserve the GSV for future arterial revascularisation and to avoid postoperative complications.2–4 Several papers have demonstrated variability in reflux patterns in patients presenting with GSV insufficiency.5,6 However, the relationship between clinical presentation and haemodynamic consequences has not been assessed in patients with non-ostial GSV reflux. The purpose of our study was to

*Corresponding author. Dr Ma´rcio Vinı´cius Lins Barros, MD, PhD, Avenida do Contorno 6760, Santo Antoˆnio, 30110-110 Belo Horizonte, MG, Brazil. E-mail address: [email protected]

evaluate anatomical and haemodynamic characteristics of patients with GSV incompetence with or without involvement of sapheno-femoral junction using duplex scanning and air plethysmography.

Methods Between April 2001 and February 2003, data on 551 limbs from 340 patients with evidence of chronic venous disease were prospectively entered into a customised database. We selected 121 limbs in 91 volunteers divided into three groups: group A consisted of 27 limbs of healthy volunteers without any clinical evidence of venous disease (controls); group B consisted of 25 limbs with GSV reflux and normal saphenous-femoral junction (SFJ) and group C consisted of 69 limbs of patients with GSV and SFJ reflux. Volunteers were members of the staff and students of the University without any sign or

1078–5884/000320 + 05 $35.00/0 q 2005 Elsevier Ltd. All rights reserved.

Clinical Significance of Ostial Great Saphenous Vein Reflux

symptoms of CVI who agreed to participate in our study. Patients in groups B and C were referred to our laboratory for evaluation of varicose vein disease. This was the main presenting complaint to their referring physician. All patients were selected at the Ecoar Noninvasive Diagnostic Medicine clinic after being screened with standardised duplex scanning and air plethysmography. The research project was assessed and approved by the Committee of Research Ethics of the Federal University of Minas Gerais. The exclusion criteria were a documented history of deep venous thrombosis by an objective method, deep venous reflux, small saphenous vein insufficiency or non-saphenous related varicosities (defined as that varicose vein in superficial veins that were not part of the greater or small saphenous systems)7 with a diameter over 4 mm. According to our experience (unpublished data from 41 consecutive patients) reticular veins are associated with normal VFI. Although we used a cut-off diameter of 4 mm most of them had veins with a diameter of !3 mm. Those criteria were used to ensure that the air plethysmography findings were related only to GSV insufficiency. All patients had a complete duplex scanning study (ATL HDI 5000 Bothell, Washington, USA) with a 7–12-MHz linear array transducer. The SFJ, common femoral, femoral, popliteal, anterior/posterior tibial, peroneal, gastrocnemius, great saphenous and small saphenous veins as well as perforators and varicosities were studied in the standing position were evaluated. The diameter of GSV was measured at six different limb levels: The SFJ, proximal and medial thirds of the thigh, the knee and medial and distal thirds of the calf. The GSV was evaluated in a transverse view. Three consecutive assessments were performed measuring the intimal-luminal interfaces with caution to avoid excessive transducer pressure during the investigation. Reflux was considered to be present only if the duration of the retrograde flow on Doppler ultrasound was greater than 0.5 s.

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Air plethysmography (model APG 1000;ACI Medical, Inc, San Marcos, Calif) was performed as previously described.8 The following parameters were evaluated: total venous volume (VV), venous filling index (VFI), residual volume fraction (RVF) and ejection fraction (EF). The VFI was further categorized in four grades: normal (!2 ml/s); mild insufficiency (2–5 ml/s); moderate (5–7 ml/s) and severe (O7 ml/s). Statistical analysis The clinical and laboratory data were analysed using the statistical package SPSS version 11 for Windows. In all tests, the indicator of statistical significance was an alpha level ! 0.05. The qualitative variables were compared in both groups by the chi-square and Fisher exact test when the expected value in any of the cells was !5. The quantitative variables were tested for normal distribution (Ryan–Joiner test) and for homogeneity of variance (Bartlett’s and Levene’s tests) with log transformations when necessary. They were described as means of the average and standard deviation. Analysis of variance (ANOVA) was carried out and the averages for the three groups were compared by the Bonferroni test.

Results There was no significant difference among the three groups in relation to age and gender. Table 1 shows the GSV diameter at the locations where measurements were made. GSV diameters were generally larger in groups B vs. A. There were also larger at corresponding sites in group C vs. B with a significant difference among the three groups in almost all segments demonstrating a clear relation between GSV diameter and the type of reflux involving this vein. Table 2 shows the distribution of the air plethysmography parameters. The VFI was greater in group B vs. A, and in group C vs. B. The VV was greater in group C

Table 1. Age (mean, standard deviation), gender and GSV diameters (mean, standard deviation) in the three different groups Variable

Group A

Group B

Group C

p

Age(years) Gender (% F/M) SFJ(mm) Proximal thigh(mm) Middle thigh (mm) Knee (mm) Middle calf (mm) Distal calf (mm)

47 SD 16 (52/48) 4.8 SD 0.3 2.3 SD 0.3 2.4 SD 0.3 2.3 SD 0.3 2.0 SD 0.3 1.9 SD 0.3

48 SD 17 (61/39) 5.2 SD 0.7 3.3 SD 0.8 3.2 SD 0.7 3.2 SD 0.8 2.8 SD 0.7 2.6 SD 0.6

48 SD 16 65/35 8.9 SD 2.5 6.0 SD 2.1 5.9 SD 2.2 5.3 SD 1.9 3.3 SD 1.1 2.8 SD 0.7

1.0* 0.4† !0.005* !0.005* !0.005* !0.005* !0.005* !0.005*

A vs. B

A vs. C

B vs. C

1.0

1.0

0.6 !0.005 0.001 0.001 !0.005 !0.005

– !0.005 !0.005 !0.005 !0.005 !0.005 !0.005

1.0 – !0.005 !0.005 !0.005 !0.005 0.053 0.3

–

* ANOVA value. † Chi-square value. Eur J Vasc Endovasc Surg Vol 31, 3 2006

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Table 2. Haemodynamic comparison by air-plethysmography among the three groups Variable

Group A

Group B

Group C

A vs. B ( p)

A vs. C ( p)

B vs. C ( p)

VFI(ml/s) EF(%) VV(ml) RV(ml)

1.2 SD 0.5 49 SD 15 106 SD 30 23 SD 13

2.0 SD 1.4 53 SD 16 116 SD 44 29 SD 17

4.0 SD 2.5 48 SD 13 141 SD 53 30 SD 18

0.02 1.0 1.0 0.24

!0.005 1.0 0.004 0.83

!.005 0.51 0.03 1.0

vs. groups A and B, but there was no statistical difference between groups A and B. No significant differences were observed in the EF and RVF. Table 3 showed a significant correlation among GSV diameters and the degree of reflux determined by air plethysmography in all patients evaluated. This correlation was better in the thigh and SFJ compared to the calf segment. Fig. 1 shows the comparative analysis of VFI in both groups. The VFI was normal in 68% of the patients with no ostial GSV insufficiency while only 4% had reflux O5 ml/s. Fig. 2 demonstrates a further stratification of VFI values in two grades (normal/mild and moderade/ severe) related to groups B and C. Patients with ostial GSV insufficiency had a great amount of reflux determined by VFI compared to those with no ostial insufficiency (pZ0.02).

Mild 1 / 4%

Normal 26 / 96%

Group A Moderate 1 / 4% Mild 7 / 28%

Discussion Saphenous vein reflux is the most common haemodynamic abnormality in patients presenting with symptoms and signs of chronic venous disease.9–11 Sapheno-femoral junction involvement has been cited as responsible for varicose vein formation. The retrograde development of reflux12 requires incompetence or absence of valves above the SFJ, which in turn causes dilatation and valvular incompetence sequentially in the GSV and its tributaries. This theory appears to be inaccurate since, saphenous reflux often exists without SFJ or sapheno-popliteal junction incompetence. The theory on the ‘weakening’ of the venous wall as the initiating factor of reflux has gained

Normal 17 / 68%

Group B Normal

Severe 9 / 13%

10 / 14%

Moderate 9 / 13%

Table 3. Correlation between GSV diameter determined by ultrasound and venous reflux determined by VFI (air plethysmography) in all volunteers Variable

r (Pearson)

p

SFJ Proximal thigh Middle thigh Knee Middle calf Distal calf

0.67 0.67 0.70 0.62 0.47 0.44

!0.01 !0.01 !0.01 !0.01 !0.01 !0.01

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Mild 41 / 59%

Group C Fig. 1. VFI severity distribution among the several groups. Distributions of mild, moderate and severe differ among the groups (p!0.001): AsB (pZ0.016), AsC (p!0.001) and BsC (p!0.001) (Bonferroni correction for multiple comparisons).

Clinical Significance of Ostial Great Saphenous Vein Reflux

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In this work, there was a significant correlation between GSV diameters and the degree of reflux determined by air plethysmography (Table 3). Our data are in concordance with a previous paper that demonstrated that the use of GSV diameters could be used as an indication of venous reflux.27 We hypothesised that in the case of a competent GSV ostial valve, the amount of blood that is refluxing in tributaries or perforators is insufficient to produce the same amount of reflux as that seen with GSV dilatation and ostial insufficiency. The total venous volume was the same in controls and those without ostial insufficiency. Our data show that although the presence of sapheno-femoral junction incompetence is not a prerequisite for varicose vein formation, its presence makes the disease more serious from a haemodynamic point of view. Previous studies have demonstrated that SFJ insufficiency is more prevalent in CVD classes 4–6,1,8,28 suggesting indirectly ascending progression of venous reflux, as previously published.14,29 It may be possible to avoid to avoid treatment of the GSV where the ostial valve of this vein remains competent on duplex scanning.

Group B Mod./severe 1 / 4%

Normal/mild 24 / 96%

Group C Mod./severe 18 / 26%

Normal/mild 51 / 74% p=0.02

Fig. 2. VFI severity distribution (normal/mild and moderate/severe) among the groups with (C) and without (B) SFJ insufficiency.

support in many functional,13,14 morphological,15,16 and biochemical studies.17,18 Nevertheless, there is a great variety in the patterns of reflux such as in the anatomical distribution of GSV and its tributaries,19,20 the frequent involvement of non-saphenous veins, reflux in the SFJ that the does not involve the GSV and so on.21,22 These patterns of reflux suggest the importance in a individualised therapy. Abu-Own et al. demonstrated that in about one-third of limbs with GSV reflux there was no associated sapheno-femoral incompetence.13 Duplex scanning has become the method of choice in the evaluation of varicose vein disease, providing direct anatomical and functional information of the entire venous system relevant to the surgical approach.22,23 Unfortunately, although the quantification of the amount of reflux by this method is feasible, it has not been used in clinical practice.24,25 The use of air plethysmography has demonstrated good correlation with the degree of insufficiency and has been extensively used in the haemodynamic study of varicose vein disease.26

Conclusions We have shown that in patients with GSV reflux those with incompetence of the ostial valve of the GSV show greater venous reflux and dilatation of the saphenous trunk than those in whom the ostial valve is competent. The treatment of the incompetent GSV should consider in addition to the presence of reflux, the GSV diameter, extent of reflux and involvement of the SFJ as well as the resulting haemodynamic severity.

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