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Recurrent varicose veins following high ligation of long saphenous vein: a duplex ultrasound study
Cardiovascular
Vol. 3, No. 5, pp. 485-487, 1Y95 Copyright @ 1995 Elscvier Science Ltd Printed in Great Britain. AI1 rights reserved Surgery,
0967~-2109i95 $10.00 + 0.00
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-
Recu~ent varicoseveinsfolkwing hlg#~E long saphenousvein: a duplex undue study Y. Tong and J. Royle Vascular Surgery Lhit, Austh Hospital Melbourne, A usfralia
Duplex scanning was used to study recurrent varicose veins in 244 limbs with previous high ligation of the long saphenous vein. The recurrent varicose veins were classified into two types according to the presence or absence of a residual long saphenous vein. Varicose veins with a residual long saphenous vein (type I) occurred in 168 limbs (68.9%). A residual long saphenous vein with an incompetent saphenofemoral junction was present in 125 limbs and one without any residual saphenofemoral junction in 43 limbs. Besides the presence of an incompetent long saphenous vein in this group, an incompetent short saphenous vein was detected in 26 limbs, incompetent perforating vein(s) in 45 limbs and incompetent deep veins in 26 limbs. Varicose veins without a residual long saphenous vein (type II) occurred in 76 limbs (31 .l%). An incompetent short saphenous vein was demonstrated in 44 limbs, incompetent perforating vein(s) in 18 limbs and incompetent deep veins in 32 limbs. of the total 244 limbs with recurrent varicose veins, long saphenous vein incompetence was involved in 168 (68.9%), short saphenous vein incompetence in 70 (28.7%). perforating vein incompetence in 63 (25.8%) and deep venous incompetence in 58 (23.8%). Although saphenofemoral junction incompetence was found to be the main source of recurrence, a segment of incompetent residual long saphenous vein, an incompetent short saphenous vein, perforating vein and deep venous system incompetence are other common sources of recurrence. A precise assessment to identify underlying venous incompetence is important for the management of recurrent varicose veins, Keywords: recurrent varicose veins, duplex ultrasound, Doppler -
Recurrence of varicose veins after surgery occurs frequently, the S-year recurrence rate being about 50%‘. The best results of further operative treatment are obtained when the source of recurrence is known before surgery213. In the investigation of recurrent varicose veins, good correlation has been found between operative findings and continuous-wave Doppler ultrasonography, venography and varicography2-4. Limitations of continuous-wave Doppler ultrasonography occur in the identification of individual incompetent veins in the presence of large superficial varicosities resulting in many false positives4. The other disadvantage of continuous-wave Doppler is that it does not demonstrate anatomy and therefore can only be complementary to anatomic studies. Venography is an
Correspondence to: Dr Y. Tong, Vascular Surgery Unit, Austin Hospital, Heidelberg, Victoria 3084, Australia
CARDIOVASCULAR SURGERY OCTOBER 199s VOL 3 NO 5
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invasive technique and creates the risk of allergic reactions to the contrast material and thrombophlebiti?. Varicography may give more accurate information but has a higher risk of thrombophlebitis’. Duplex venous imaging overcomes the disadvantage of continuous-wave Doppler examination by providing detailed anatomic information and accurately localizing the site of reflux 6T7.Duplex imaging is a non-invasive examination which avoids the inherent risks of venography yet provides additional qualitative haemodynamic information.
Patients and methods A total of 169 patients (244 limbs) with recurrent varicose veins were evaluated using duplex imaging. All patients had received a high ligation of the long saphenous vein; those with previous short saphenous vein ligation or nick and pick were not included in this study. 485
Recurrent varicose veins and long Sapnenous vein ligation: Y Tong and J Royle
Duplex ultrasonographic examinations were performed with the Ultramark 9 Ultrasound System (Advanced Technology Laboratories, Bothell, Washington, USA). A S-MHz linear imaging probe, coupled with S-MHz pulsed Doppler signal, was used. Veins in the groin and thigh were tested with the patient in a supine position with 30 degree of reversed Trendelenburg tilt. Examination of the popliteal fossa and calf was performed with the patient in a sitting position. The direction of venous flow was tested by manual compression and release on thigh or calf. Hard copies of real-time ultrasound image, colour flow image and Doppler grey scale spectrum were recorded and analysed. Venous reflux in the groin and the popliteal fossa was also assessedwith a S-MHz continuous-wave Doppler ultrasound probe (Model 1052, Parks Medical Electronic, Aloha, Oregon, USA) independently by one of the authors (J. R.) in 118 of the 244 limbs. Patients were tested in the standing position and the presence or absence of reflux was assessedduring release of calf or thigh compression as previously described’.
Results The recurrent varicose veins were classified into two types according to the presence or absenceof a residual incompetent long saphenous vein. Type I Varicose veins with a residual long saphenous vein occurred in 168 limbs (68.9%). A residual long saphenous vein with an incompetent saphenofemoral junction was present in 125 limbs and a residual incompetent long saphenous vein without incompetent saphenofemoral junction in 43 limbs. Besides the presence of an incompetent long saphenous vein in this group, an incompetent short saphenous vein was detected in 26 limbs, incompetent perforating vein(s) in 45 limbs and incompetent deep veins in 26 limbs. Type II Varicose veins without an incompetent residual long saphenous vein occurred in 76 limbs (3 1.1%). An incompetent short saphenous vein was demonstrated in 44 limbs, incompetent perforating vein(s) in 18 limbs and incompetent deep veins in 32 limbs. A competent residual long saphenous vein was present in eight limbs. Of the total 244 limbs with recurrent varicose veins, long saphenous vein incompetence was involved in 168 (68.9%), short saphenous vein incompetence in 70 (28.7%), perforating vein incompetence in 63 (25.8%) and deep venous incompetence in 58 (23.8 %). In 118 limbs investigated with continuous-wave Doppler and duplex studies, duplex scanning confirmed the reflux found by continuous-wave Doppler in 106 cases (89.8%) and the precise source of the reflux was 486
identified. There were 12 regions in which retlux detected by continuous-wave Doppler was not confirmed by duplex scan, i.e. continuous-wave Doppler gave a false positive result. The duplex ultrasonographic study revealed no reflux in any individual veins in those 12 specific regions. Two types of anatomy were noted in these regions. Two or more superficial veins joined the deep venous system via a common junction in six cases. The short saphenous vein and a descending popliteal area vein joined the popliteal vein with a common junction (one of these also had a common junction with a gastrocnemius vein) in three casesand a gastrocnemius vein and a popliteal area vein with a common junction in three. A descending vein joined the deep venous system in six cases.The superficial epigastric vein joined the common femoral vein (after high ligation of the long saphenous vein) in three cases and a descending popliteal area vein joined the popliteal vein in the remaining three.
Discussion Recurrent saphenofemoral junction incompetence was found to be the main source of recurrence after high ligation of the long saphenous vein. It was involved in 51.2% of the recurrent varicose veins following previous surgery of this type. The incompetent saphenofemoral junction was usually found at operation to be a residual long saphenous vein stump into which enlarged tributaries drained. These communicated with a residual long saphenous vein a few centimetres distally. Some patients had a completely intact long saphenous vein and at the original operation clearly a large subsidiary, probably the lateral accessory saphenous vein, had been ligated flush with the saphenous vein in the mistaken belief that a saphenofemoral ligation was being undertaken. A segment of incompetent residual long saphenous vein was demonstrated to be another common source of the recurrence (17.6%). Those residual veins were sometimes undiagnosed by clinical examination or continuous-wave Doppler study, especially in a patient with an obese limb. A careful duplex examination to identify the residual long saphenous vein and preoperative marking of the course of the vein on the skin surface enabled further surgery to be more complete. Competent residual long saphenous veins were found in some patients with type II recurrence. It is recommended to preserve those veins since they may be needed for a vascular reconstruction at some stage. An incompetent short saphenous vein, perforating vein and deep venous system incompetence were other common sources for recurrence. They may be present with or without recurrent or residual long saphenous veins. Precise assessmentby duplex scanning is required to identify those sources of venous incompetence which might have been present and undiagnosed before previous surgery or developed after that surgery. CARIIIOVASCULAR SURGERY OCTOBER 1995 VOL 3 NO 5
Recurrent varicose veins and long Sapnenous vein ligation: P Tity and J. Royk?
False reflux suggested by continuous-wave Doppler was demonstrated in 10.2% of limbs using Duplex ultrasound. The false reflux appeared in areas where two or more superficial veins joined a deep vein via a common junction from opposite directions. When the Doppler probe is interrogating a sample volume in such a junction, a bidirectional Doppler signal can be detected by manual compression and sudden release of the thigh or calf. This is, in fact, a combined venous flow from two distinct individual vessels.The ascending flow is heard from the vein below the junction during distal compression and the descending flow is heard from the vein above the junction following release of the compression. Similarly, bidirectional flow, thought to be reflux, can be found in an area with a descending vein joining the deep venous system since continuous-wave Doppler is unable to distinguish venous flow originating from more than one vein. Normal caudally directed venous flow in the descending vein following release of the compression could be misinterpreted as venous reflux. This anatomic arrangement is readily apparent when a colour duplex examination is used. A knowledge of the variations of venous anatomy and pathophysiology is, important for clinicians when interpreting the signals obtained during continuous-wave Doppler assessment.When there is doubt about the conclusions to be reached with this technique, duplex scanning can be used to clarify the interpretation’. The results of this study indicate that recurrent saphenofemoral junction incompetence is the main source of recurrence of varicose veins following high ligation of the long saphenous vein. A segment of
CARDIOVASCULAR SURGERY OCTOBER 1995 VOL 3 NO S
incompetent residual long saphenous vein, an incompetent short saphenous vein, perforating vein and deep venous system incompetence are other common sources of recurrence. A precise assessmentto identify underlying venous incompetence is important for the management of recurrent varicose veins.
References 1. Juhan C, Haupert S, Miltgen G et al. Recurrent vartcose veins. Phlebology 1990; 5: 201-11. 2. Lea Thomas M, Phillips GW. Recurrent groin varicose veins: an assessment by descending phlebography. Rr / Radio1 1988; 63: 294-6. 3. Loveday EJ, Lea Thomas M. The distributron of recurrent varicose veins: a phlebographic study. Clin Radial 1991; 43: 47-51. 4. Royle JP. Recurrent varicose veins. tY’orlr2 j Stir8 1986; 10: 944-53. 5. Lea Thomas M, Bowles JN. Incompetent perforating veins: comparison of varicography and ascending phlebography. Radiolonv-, 1985: 154: 619-23. 6. Thibault P, Bray A, Wlodarczyk J et ai. Cosmetic leg veins: evaluation using duplex venous imaging. f Dcmcztol Surg Oncol 1990; 16: 612-18. of 7. Vasdekis SN, Clarke GH, Nicolaides MS. Quantification venous reflux by means of duplex scanning. ] V*zsc Surg 1989; 10: 670-7. 8. Hoare MC, Koyle JP. Doppler ultrasound derecnon of saphenofemoral and saphenopopliteal incompetence and operative venography to ensure precise saphenopophteai hgation. Aust NZ J Surg 1984; 54: 49-52. 9. Tong Y, Royal J. An anatomic source of false venous reflux with continuous wave Doppler. I Dmatol .Snrrg Gmol 1994; 20: 676-8. Paper accepted 20 May 1994
487
Vol. 3, No. 5, pp. 485-487, 1Y95 Copyright @ 1995 Elscvier Science Ltd Printed in Great Britain. AI1 rights reserved Surgery,
0967~-2109i95 $10.00 + 0.00
-
-
Recu~ent varicoseveinsfolkwing hlg#~E long saphenousvein: a duplex undue study Y. Tong and J. Royle Vascular Surgery Lhit, Austh Hospital Melbourne, A usfralia
Duplex scanning was used to study recurrent varicose veins in 244 limbs with previous high ligation of the long saphenous vein. The recurrent varicose veins were classified into two types according to the presence or absence of a residual long saphenous vein. Varicose veins with a residual long saphenous vein (type I) occurred in 168 limbs (68.9%). A residual long saphenous vein with an incompetent saphenofemoral junction was present in 125 limbs and one without any residual saphenofemoral junction in 43 limbs. Besides the presence of an incompetent long saphenous vein in this group, an incompetent short saphenous vein was detected in 26 limbs, incompetent perforating vein(s) in 45 limbs and incompetent deep veins in 26 limbs. Varicose veins without a residual long saphenous vein (type II) occurred in 76 limbs (31 .l%). An incompetent short saphenous vein was demonstrated in 44 limbs, incompetent perforating vein(s) in 18 limbs and incompetent deep veins in 32 limbs. of the total 244 limbs with recurrent varicose veins, long saphenous vein incompetence was involved in 168 (68.9%), short saphenous vein incompetence in 70 (28.7%). perforating vein incompetence in 63 (25.8%) and deep venous incompetence in 58 (23.8%). Although saphenofemoral junction incompetence was found to be the main source of recurrence, a segment of incompetent residual long saphenous vein, an incompetent short saphenous vein, perforating vein and deep venous system incompetence are other common sources of recurrence. A precise assessment to identify underlying venous incompetence is important for the management of recurrent varicose veins, Keywords: recurrent varicose veins, duplex ultrasound, Doppler -
Recurrence of varicose veins after surgery occurs frequently, the S-year recurrence rate being about 50%‘. The best results of further operative treatment are obtained when the source of recurrence is known before surgery213. In the investigation of recurrent varicose veins, good correlation has been found between operative findings and continuous-wave Doppler ultrasonography, venography and varicography2-4. Limitations of continuous-wave Doppler ultrasonography occur in the identification of individual incompetent veins in the presence of large superficial varicosities resulting in many false positives4. The other disadvantage of continuous-wave Doppler is that it does not demonstrate anatomy and therefore can only be complementary to anatomic studies. Venography is an
Correspondence to: Dr Y. Tong, Vascular Surgery Unit, Austin Hospital, Heidelberg, Victoria 3084, Australia
CARDIOVASCULAR SURGERY OCTOBER 199s VOL 3 NO 5
---.--
-._----.
invasive technique and creates the risk of allergic reactions to the contrast material and thrombophlebiti?. Varicography may give more accurate information but has a higher risk of thrombophlebitis’. Duplex venous imaging overcomes the disadvantage of continuous-wave Doppler examination by providing detailed anatomic information and accurately localizing the site of reflux 6T7.Duplex imaging is a non-invasive examination which avoids the inherent risks of venography yet provides additional qualitative haemodynamic information.
Patients and methods A total of 169 patients (244 limbs) with recurrent varicose veins were evaluated using duplex imaging. All patients had received a high ligation of the long saphenous vein; those with previous short saphenous vein ligation or nick and pick were not included in this study. 485
Recurrent varicose veins and long Sapnenous vein ligation: Y Tong and J Royle
Duplex ultrasonographic examinations were performed with the Ultramark 9 Ultrasound System (Advanced Technology Laboratories, Bothell, Washington, USA). A S-MHz linear imaging probe, coupled with S-MHz pulsed Doppler signal, was used. Veins in the groin and thigh were tested with the patient in a supine position with 30 degree of reversed Trendelenburg tilt. Examination of the popliteal fossa and calf was performed with the patient in a sitting position. The direction of venous flow was tested by manual compression and release on thigh or calf. Hard copies of real-time ultrasound image, colour flow image and Doppler grey scale spectrum were recorded and analysed. Venous reflux in the groin and the popliteal fossa was also assessedwith a S-MHz continuous-wave Doppler ultrasound probe (Model 1052, Parks Medical Electronic, Aloha, Oregon, USA) independently by one of the authors (J. R.) in 118 of the 244 limbs. Patients were tested in the standing position and the presence or absence of reflux was assessedduring release of calf or thigh compression as previously described’.
Results The recurrent varicose veins were classified into two types according to the presence or absenceof a residual incompetent long saphenous vein. Type I Varicose veins with a residual long saphenous vein occurred in 168 limbs (68.9%). A residual long saphenous vein with an incompetent saphenofemoral junction was present in 125 limbs and a residual incompetent long saphenous vein without incompetent saphenofemoral junction in 43 limbs. Besides the presence of an incompetent long saphenous vein in this group, an incompetent short saphenous vein was detected in 26 limbs, incompetent perforating vein(s) in 45 limbs and incompetent deep veins in 26 limbs. Type II Varicose veins without an incompetent residual long saphenous vein occurred in 76 limbs (3 1.1%). An incompetent short saphenous vein was demonstrated in 44 limbs, incompetent perforating vein(s) in 18 limbs and incompetent deep veins in 32 limbs. A competent residual long saphenous vein was present in eight limbs. Of the total 244 limbs with recurrent varicose veins, long saphenous vein incompetence was involved in 168 (68.9%), short saphenous vein incompetence in 70 (28.7%), perforating vein incompetence in 63 (25.8%) and deep venous incompetence in 58 (23.8 %). In 118 limbs investigated with continuous-wave Doppler and duplex studies, duplex scanning confirmed the reflux found by continuous-wave Doppler in 106 cases (89.8%) and the precise source of the reflux was 486
identified. There were 12 regions in which retlux detected by continuous-wave Doppler was not confirmed by duplex scan, i.e. continuous-wave Doppler gave a false positive result. The duplex ultrasonographic study revealed no reflux in any individual veins in those 12 specific regions. Two types of anatomy were noted in these regions. Two or more superficial veins joined the deep venous system via a common junction in six cases. The short saphenous vein and a descending popliteal area vein joined the popliteal vein with a common junction (one of these also had a common junction with a gastrocnemius vein) in three casesand a gastrocnemius vein and a popliteal area vein with a common junction in three. A descending vein joined the deep venous system in six cases.The superficial epigastric vein joined the common femoral vein (after high ligation of the long saphenous vein) in three cases and a descending popliteal area vein joined the popliteal vein in the remaining three.
Discussion Recurrent saphenofemoral junction incompetence was found to be the main source of recurrence after high ligation of the long saphenous vein. It was involved in 51.2% of the recurrent varicose veins following previous surgery of this type. The incompetent saphenofemoral junction was usually found at operation to be a residual long saphenous vein stump into which enlarged tributaries drained. These communicated with a residual long saphenous vein a few centimetres distally. Some patients had a completely intact long saphenous vein and at the original operation clearly a large subsidiary, probably the lateral accessory saphenous vein, had been ligated flush with the saphenous vein in the mistaken belief that a saphenofemoral ligation was being undertaken. A segment of incompetent residual long saphenous vein was demonstrated to be another common source of the recurrence (17.6%). Those residual veins were sometimes undiagnosed by clinical examination or continuous-wave Doppler study, especially in a patient with an obese limb. A careful duplex examination to identify the residual long saphenous vein and preoperative marking of the course of the vein on the skin surface enabled further surgery to be more complete. Competent residual long saphenous veins were found in some patients with type II recurrence. It is recommended to preserve those veins since they may be needed for a vascular reconstruction at some stage. An incompetent short saphenous vein, perforating vein and deep venous system incompetence were other common sources for recurrence. They may be present with or without recurrent or residual long saphenous veins. Precise assessmentby duplex scanning is required to identify those sources of venous incompetence which might have been present and undiagnosed before previous surgery or developed after that surgery. CARIIIOVASCULAR SURGERY OCTOBER 1995 VOL 3 NO 5
Recurrent varicose veins and long Sapnenous vein ligation: P Tity and J. Royk?
False reflux suggested by continuous-wave Doppler was demonstrated in 10.2% of limbs using Duplex ultrasound. The false reflux appeared in areas where two or more superficial veins joined a deep vein via a common junction from opposite directions. When the Doppler probe is interrogating a sample volume in such a junction, a bidirectional Doppler signal can be detected by manual compression and sudden release of the thigh or calf. This is, in fact, a combined venous flow from two distinct individual vessels.The ascending flow is heard from the vein below the junction during distal compression and the descending flow is heard from the vein above the junction following release of the compression. Similarly, bidirectional flow, thought to be reflux, can be found in an area with a descending vein joining the deep venous system since continuous-wave Doppler is unable to distinguish venous flow originating from more than one vein. Normal caudally directed venous flow in the descending vein following release of the compression could be misinterpreted as venous reflux. This anatomic arrangement is readily apparent when a colour duplex examination is used. A knowledge of the variations of venous anatomy and pathophysiology is, important for clinicians when interpreting the signals obtained during continuous-wave Doppler assessment.When there is doubt about the conclusions to be reached with this technique, duplex scanning can be used to clarify the interpretation’. The results of this study indicate that recurrent saphenofemoral junction incompetence is the main source of recurrence of varicose veins following high ligation of the long saphenous vein. A segment of
CARDIOVASCULAR SURGERY OCTOBER 1995 VOL 3 NO S
incompetent residual long saphenous vein, an incompetent short saphenous vein, perforating vein and deep venous system incompetence are other common sources of recurrence. A precise assessmentto identify underlying venous incompetence is important for the management of recurrent varicose veins.
References 1. Juhan C, Haupert S, Miltgen G et al. Recurrent vartcose veins. Phlebology 1990; 5: 201-11. 2. Lea Thomas M, Phillips GW. Recurrent groin varicose veins: an assessment by descending phlebography. Rr / Radio1 1988; 63: 294-6. 3. Loveday EJ, Lea Thomas M. The distributron of recurrent varicose veins: a phlebographic study. Clin Radial 1991; 43: 47-51. 4. Royle JP. Recurrent varicose veins. tY’orlr2 j Stir8 1986; 10: 944-53. 5. Lea Thomas M, Bowles JN. Incompetent perforating veins: comparison of varicography and ascending phlebography. Radiolonv-, 1985: 154: 619-23. 6. Thibault P, Bray A, Wlodarczyk J et ai. Cosmetic leg veins: evaluation using duplex venous imaging. f Dcmcztol Surg Oncol 1990; 16: 612-18. of 7. Vasdekis SN, Clarke GH, Nicolaides MS. Quantification venous reflux by means of duplex scanning. ] V*zsc Surg 1989; 10: 670-7. 8. Hoare MC, Koyle JP. Doppler ultrasound derecnon of saphenofemoral and saphenopopliteal incompetence and operative venography to ensure precise saphenopophteai hgation. Aust NZ J Surg 1984; 54: 49-52. 9. Tong Y, Royal J. An anatomic source of false venous reflux with continuous wave Doppler. I Dmatol .Snrrg Gmol 1994; 20: 676-8. Paper accepted 20 May 1994
487