- Email: [email protected]
Quantifying Saphenous Recirculation in Patients With Superficial Venous Insufficiency
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS Volume 3, Number 1
Abstracts 133
Nothing to disclose; T. W. Wakefield: Nothing to disclose; D. M. Coleman: Nothing to disclose. Quantifying Saphenous Recirculation in Patients With Superficial Venous Insufficiency C. R. Lattimer, M. Azzam, E. Kalodiki, G. Geroulakos. Ealing Hospital & Imperial College, Middlesex, United Kingdom Objectives: The great saphenous vein (GSV) in patients with superficial venous insufficiency may act as a beneficial conduit for antegrade venous drainage and also as a harmful conduit promoting reflux/recirculation and subsequent skin changes. The aim of this study was to measure the antegrade and retrograde GSV volume displacements during calf compression and release maneuvers. This was used to quantify harm over benefit with a recirculation index (RCI). Methods: Sixteen legs (16 patients, nine right, nine male) with superficial venous insufficiency were scanned standing, at the upper thigh GSV, with duplex ultrasonography. The clinical CEAP class was as follows: C2, three; C3, two; C4a, six; C4b, four; and C5, one. The median (range) age, Venous Clinical Severity Score, and GSV diameter were 63 (21-79) years, 8 (4-16), and 7 (5-10) mm, respectively. A manual calf compression and release (MCCR) maneuver was performed once and an automated calf compression and release (ACCR) three times for reproducibility. The calf-cuff and inflation/deflation pump (ArtAssist; ACI Medical, San Marcos, Calif) provided a cyclical compression pressure of 120 mm Hg (3 seconds) with a release time of 16.4 seconds to allow adequate venous refilling (Fig). Results: Expressed as median [interquartile range]: (1) The ACCR compared with the MCCR resulted in longer reflux duration (16.4 [8.216.4] seconds vs 5.7 [3.7-6.8] seconds; P < .0005), higher peak reflux velocities (64.8 [38.3-77.4] cm/s vs 58.8 [42-68] cm/s; P ¼ .298), higher time-averaged mean velocities (TAMVs) in reflux (23.5 [14.9-27.9] cm/s vs 14.1 [9-17.6] cm/s; P < .0005), and greater reflux volume displacements (81.7 [38.8-152.8] mL vs 27.3 [16.4-53.4] mL; P < .0005). (2) Furthermore, there were significant correlations between increasing antegrade volume measurements and increasing reflux volume measurements irrespective of whether ACCR or MCCR was used (Table). This implies that the displaced antegrade volume has a large effect on the resulting reflux volume. (3) The ratio of reflux volume/antegrade volume (RCI) was 2.14 [1.58-2.74] with the ACCR. Adjusted to a standard median for each leg, the reproducibility limit (3) of the RCI was excellent at 2.14 (95% confidence interval, 2.09-2.21). Conclusions: This study measured the behavior of the GSV in terms of harmful reflux over beneficial drainage by the RCI. It recognizes that reflux values depend on the type of provocation test and the amount of displaced antegrade volume. This limitation may be overcome by factoring reflux as an expression of antegrade flow by the RCI. Once it is standardized, a test for quantifying saphenous recirculation may have many clinical applications. The next step will be to correlate the RCI with clinical and quality of life parameters.
Fig 1. An applied calf-cuff with the automated compression cycle specifications along-side. Table. Correlations between antegrade and reflux flow parameters
Antegrade Manual (MCCR) Duration, 1.4 (1.0-1.6) seconds TAMV, cm/s 15.7 (10.5-15.7) Volume, mL 6.0 (4.5-17.8) Automated (ACCR) Duration, 4.0 (3.2-5.5) seconds TAMV, cm/s 22.4 (17.3-25.3) Volume, mL 37.1 (16.3-58.3)
Reflux
5.7 (3.7-6.8) 14.1 (9.0-17.6) 27.3 (16.4-53.4) 16.4 (8.2-16.4) 23.5 (14.9-27.9) 81.7 (38.8-152.8)
r value, P Spearman value .189
.483
.258 .762
.336 .001
.153
.571
.664 .841
.005 <.0005
ACCR, Automated calf compression and release; MCCR, manual calf compression and release; TAMV, time-averaged mean velocity. Significance is when P < .05. Author Disclosures: C. R. Lattimer: Nothing to disclose; M. Azzam: Nothing to disclose; E. Kalodiki: Nothing to disclose; G. Geroulakos: Nothing to disclose.
Abstracts 133
Nothing to disclose; T. W. Wakefield: Nothing to disclose; D. M. Coleman: Nothing to disclose. Quantifying Saphenous Recirculation in Patients With Superficial Venous Insufficiency C. R. Lattimer, M. Azzam, E. Kalodiki, G. Geroulakos. Ealing Hospital & Imperial College, Middlesex, United Kingdom Objectives: The great saphenous vein (GSV) in patients with superficial venous insufficiency may act as a beneficial conduit for antegrade venous drainage and also as a harmful conduit promoting reflux/recirculation and subsequent skin changes. The aim of this study was to measure the antegrade and retrograde GSV volume displacements during calf compression and release maneuvers. This was used to quantify harm over benefit with a recirculation index (RCI). Methods: Sixteen legs (16 patients, nine right, nine male) with superficial venous insufficiency were scanned standing, at the upper thigh GSV, with duplex ultrasonography. The clinical CEAP class was as follows: C2, three; C3, two; C4a, six; C4b, four; and C5, one. The median (range) age, Venous Clinical Severity Score, and GSV diameter were 63 (21-79) years, 8 (4-16), and 7 (5-10) mm, respectively. A manual calf compression and release (MCCR) maneuver was performed once and an automated calf compression and release (ACCR) three times for reproducibility. The calf-cuff and inflation/deflation pump (ArtAssist; ACI Medical, San Marcos, Calif) provided a cyclical compression pressure of 120 mm Hg (3 seconds) with a release time of 16.4 seconds to allow adequate venous refilling (Fig). Results: Expressed as median [interquartile range]: (1) The ACCR compared with the MCCR resulted in longer reflux duration (16.4 [8.216.4] seconds vs 5.7 [3.7-6.8] seconds; P < .0005), higher peak reflux velocities (64.8 [38.3-77.4] cm/s vs 58.8 [42-68] cm/s; P ¼ .298), higher time-averaged mean velocities (TAMVs) in reflux (23.5 [14.9-27.9] cm/s vs 14.1 [9-17.6] cm/s; P < .0005), and greater reflux volume displacements (81.7 [38.8-152.8] mL vs 27.3 [16.4-53.4] mL; P < .0005). (2) Furthermore, there were significant correlations between increasing antegrade volume measurements and increasing reflux volume measurements irrespective of whether ACCR or MCCR was used (Table). This implies that the displaced antegrade volume has a large effect on the resulting reflux volume. (3) The ratio of reflux volume/antegrade volume (RCI) was 2.14 [1.58-2.74] with the ACCR. Adjusted to a standard median for each leg, the reproducibility limit (3) of the RCI was excellent at 2.14 (95% confidence interval, 2.09-2.21). Conclusions: This study measured the behavior of the GSV in terms of harmful reflux over beneficial drainage by the RCI. It recognizes that reflux values depend on the type of provocation test and the amount of displaced antegrade volume. This limitation may be overcome by factoring reflux as an expression of antegrade flow by the RCI. Once it is standardized, a test for quantifying saphenous recirculation may have many clinical applications. The next step will be to correlate the RCI with clinical and quality of life parameters.
Fig 1. An applied calf-cuff with the automated compression cycle specifications along-side. Table. Correlations between antegrade and reflux flow parameters
Antegrade Manual (MCCR) Duration, 1.4 (1.0-1.6) seconds TAMV, cm/s 15.7 (10.5-15.7) Volume, mL 6.0 (4.5-17.8) Automated (ACCR) Duration, 4.0 (3.2-5.5) seconds TAMV, cm/s 22.4 (17.3-25.3) Volume, mL 37.1 (16.3-58.3)
Reflux
5.7 (3.7-6.8) 14.1 (9.0-17.6) 27.3 (16.4-53.4) 16.4 (8.2-16.4) 23.5 (14.9-27.9) 81.7 (38.8-152.8)
r value, P Spearman value .189
.483
.258 .762
.336 .001
.153
.571
.664 .841
.005 <.0005
ACCR, Automated calf compression and release; MCCR, manual calf compression and release; TAMV, time-averaged mean velocity. Significance is when P < .05. Author Disclosures: C. R. Lattimer: Nothing to disclose; M. Azzam: Nothing to disclose; E. Kalodiki: Nothing to disclose; G. Geroulakos: Nothing to disclose.