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Functional anatomic classification of saphenous vein insufficiency in the planning for varicose vein surgery based on color Doppler ultrasound
(Portuguese PDF version)

Carlos Alberto Engelhorn¹, Ana Luiza Engelhorn², Maria Fernanda Cassou³, Cassiana Casagrande Zanoni², Carlos José Gosalan², Emerson Ribas²

1. Professor of Angiology, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil.
2. Physician, Vascular Laboratory, Santa Casa de Misericórdia de Curitiba, Curitiba, PR, Brazil.
3. Undergraduate student of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil.

Correspondence:
Carlos Alberto Engelhorn
Rua Deputado Heitor Alencar Furtado, 1720/901
CEP: 81200-110 - Curitiba, PR
Brazil
E-mail:engelhorn@bsi.com.br

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ABSTRACT

Objective: The objective of this study is to present a functional classification of reflux patterns in saphenous veins based on color Doppler ultrasound, and to determine the sites of reflux and drainage in order to guide the surgeon in the surgical planning.

Methods: From June to December 2002, color Doppler ultrasound was used to study prospectively 1,740 lower extremities from 910 patients complaining of chronic venous insufficiency. There were 128 male and 782 female patients, with average age of 41 years. Of these 1,740 limbs, 324 were excluded because they presented past chronic deep venous thrombosis or underwent previous varicose vein surgery. The patterns of reflux for the great and short saphenous veins were established according to the sources of reflux and sites of drainage. From the 1,416 extremities included in the study, 718 were right lower limbs and 692 were left lower limbs.

Results: The great saphenous vein had no reflux in 398 lower limbs (28.11%). A total of six different patterns of reflux were identified to the great saphenous vein, and the isolated segmental reflux was the most common (33.54%) of them. The main sources of reflux and sites of drainage in the great saphenous vein were the tributaries of the leg (44.78% and 33.97%, respectively). The short saphenous vein was normal in 1,132 extremities (79.94%). A total of six different patterns of reflux were identified to the short saphenous vein, and the isolated segmental reflux was the most common (8.47%) of them. The main sources of reflux and sites of drainage in the short saphenous vein were also the tributaries (70.24% and 83.33%, respectively). The most common place of the saphenofemoral junction was at the popliteal fold (54.6%). Deep venous reflux occurred in 3.53% of the lower limbs.

Conclusion: The classification proposed gives salience to the different types of reflux in and short saphenous veins and to the importance of the surgical planning in the treatment of lower limb varicose veins in order to avoid recurrent varicose veins or unnecessary removal of saphenous veins.

Key-words: ultrasonography, saphenous vein, color doppler ultrasonography.
Palavras-chave: ultra-som, veia safena, ultra-sonografia doppler em cores.

J Vasc Br 2004;3(1):13-9

Surgical treatment of lower limb varicose veins has undergone a huge transformation after the routine use of color Doppler ultrasound, allowing for a better preoperative planning and more safety for the surgeon in performing the procedure. Following the current tendency for preserving saphenous veins, it is fundamental to evaluate the lower limb superficial venous system preoperatively. The identification of specific reflux patterns allows for an individual approach to each lower limb of the patient.

The objective of the this study is to present a revised/wide-ranging functional anatomic classification of reflux patterns in saphenous veins based on color Doppler ultrasound and to determine sites of reflux and drainage in order to guide the surgeon in his/her preoperative planning.

CASES AND METHODOLOGY

Population

From June to December 2002, 1,740 lower limbs of 910 consecutive patients were studied prospectively with color Doppler ultrasound. The patients complained of chronic venous insufficiency. A hundred twenty-eight patients were males and 782 were females, with an average age of 41 years. Of the 1,740 limbs, 324 were excluded because they presented past deep venous thrombosis or underwent previous varicose vein surgery. Of the other 1,416 limbs, 295 (21%) were clinically classified (CEAP classification) in types 0 and 1, and the other limbs in types 2 to 6, with complaints of pain and edema in lower limbs.

Methodology

Patients were evaluated with Siemens-Elegra® color Doppler ultrasound system according to the following routine examination:¹

1. Evaluation of competence of the deep venous system in order to exclude cases of
recent or past venous thrombosis. With the patient in supine position, transverse b-mode imaging and maneuvers of compressing the veins were performed with low-frequency transducers (5 MHz).

2. Evaluation of great and short saphenous veins, performed with the patient in upright position. Greatitudinal imaging was obtained with a high-frequency transducer (7 MHz). With the color mapping of the blood flow, valve function was evaluated with Valsalva maneuver and distal limb compression in order to identify superficial venous reflux.

3. Search for sources of reflux and drainage. The sources of reflux usually evaluated in the saphenous vein were saphenofemoral junction, tributaries of the saphenous vein at the groin, perforating veins and tributaries of the short saphenous vein or perforating veins. The sites of drainage of the saphenous vein examined were tributaries and perforating veins in thigh and leg level.

In the evaluation of the short saphenous vein, we identified the sources of reflux (groin, perforating veins and tributaries) and sites of drainage (perforating veins and tributaries), and attempted at identifying precisely the point of communication with the deep venous system (saphenopopliteal junction, muscular veins, etc.) as well as other sites of reflux (Giacomini vein) relevant for the analysis.

According to the sources of reflux and sites of drainage, reflux patterns were established for great and short saphenous veins.

The quantification of reflux was based on the criteria of van Bemmelen et al.,² considering a reflux peak of 30cm/s or higher (with limb at 60° angle) or duration of reflux greater than 0.5s as significant values.

RESULTS

Of the 1,416 limbs included in the study, 718 were right lower limbs and 692 were left lower limbs.

Evaluation of saphenous veins

Reflux patterns

There was no venous reflux in 398 saphenous veins (28.11%). Based on the evaluation of saphenous veins with signs of valvular incompetence, six different reflux patterns for the saphenous vein were identified, as illustrated in Figure 1 and detailed below:

1. Reflux pattern type I - medial junction - characterized by reflux in the saphenofemoral junction drained by tributaries at the groin (accessory saphenous veins, pudendal veins, circumflex veins, etc.), with valvular competence of the saphenous vein.

2. Reflux pattern type II - proximal - characterized by reflux in the saphenofemoral junction and in the saphenous vein , drained by superficial tributary or perforating vein at thigh or leg level. Valvular competence remains in the rest of the great saphenous vein.

3. Reflux pattern type III - distal - characterized by absence of reflux in saphenofemoral junction and in proximal saphenous vein, and by the presence of reflux in the great saphenous vein up to the medial malleolus, caused by superficial tributary or perforating vein at thigh or leg level.

4. Reflux pattern type IV - segmental - characterized by reflux in a single segment of the great saphenous vein at thigh and/or leg level, drained by the tributary or perforating vein. No impairement to the saphenofemoral junction.

5. Reflux pattern type V - multisegmental - characterized by reflux in two or more segments of the great saphenous vein at thigh and/or leg level. This reflux pattern is divided into two subtypes: Va - affects saphenofemoral junction; and Vb - does not affect saphenofemoral junction.

6. Reflux pattern type VI - diffuse - characterized by reflux in the whole of the great saphenous vein, from the saphenofemoral junction up to the medial malleolus.

Figure 1- Reflux patterns in LSV.

Concerning reflux patterns, the most common among the great saphenous veins under study was type IV - segmental reflux (33.54%), followed by type Vb - multisegmental reflux not affecting the saphenofemoral junction (14.62%), type III - distal reflux (9.81%), type II - proximal reflux (5.65%), type Va - multisegmental reflux affecting the saphenofemoral junction (4.45%), type VI - diffuse reflux (3.11%) and type I - medial junction (0.71%).

Sources of reflux

The analysis of sources of reflux in great saphenous veins evidenced predominance of valvular insufficiency in tributaries of the leg (44.78%), tributaries of the thigh (25.30%), saphenofemoral junction (15%), tributaries of the knee (9.54%), perforating vein of the leg (3.81%), perforating vein of the thigh (1.16%) and perforating vein of the knee (0.41%). Results are detailed in Table 1.

Table 1- Sources of reflux in great saphenous vein (GSV)

GSV - Sources of reflux	n	%
Saphenofemoral junction	181	15.0
Thigh - tributary - perforating vein	305 14	25.3 1.16
Knee - tributary - perforating vein	115 5	9.54 0.41
Leg - tributary - perforating vein	540 46	44.78 3.81
Total	1,206	100

Sites of drainage

Concerning the sites of drainage of reflux in the great saphenous vein (Table 2), the most common site observed was the tributaries of the leg (33.97%), followed by tributaries of the thigh (28.68%), perforating vein of the leg (19.15%), tributaries of the knee (9.95%), perforating vein of the thigh (7.09%) and perforating vein of the knee (1.16%).

Table 2- Sites of drainage in great saphenous vein (GSV)

GSV- Sites of drainage	n	%
Thigh - tributary - perforating vein	271 67	28.68 7.09
Knee - tributary - perforating vein	94 11	9.95 1.16
Leg - tributary - perforating vein	321 181	33.97 19.15
Total	945	100

Evaluation of short saphenous vein

Reflux patterns

There was no venous reflux in 1,132 short saphenous veins (79.94%). Based on the evaluation of short saphenous veins with signs of valvular incompetence, six different reflux patterns for the short saphenous vein were identified, as illustrated in Figure 2 and detailed below:

1. Reflux pattern type I - Giacomini vein (in posterior thigh, connects short saphenous vein at the saphenopopliteal junction to the great saphenous vein at the proximal third of the thigh) - characterized by reflux in Giacomini vein, with no signs of valvular incompetence in the short saphenous vein.

2. Reflux pattern type II - proximal - characterized by reflux in the saphenopopliteal junction and in the short saphenous vein, drained by superficial tributary or perforating vein at leg level. Valvular competence remains in the rest of the short saphenous vein.

3. Reflux pattern type III - distal - characterized by absence of reflux in saphenopopliteal junction and by the presence of reflux in the short saphenous vein up to the medial malleolus, caused by superficial tributary or perforating vein at proximal, medial or distal level of the leg.

4. Reflux pattern type IV - segmental - characterized by reflux in a single segment of the short saphenous vein at leg level. No impairement to the saphenopopliteal junction.

5. Reflux pattern type V - multisegmental - characterized by reflux in two or more segments of the short saphenous vein at leg level. This reflux pattern is divided into two subtypes: Va - affects saphenopopliteal junction; and Vb - does not affect saphenopopliteal junction.

6. Reflux pattern type VI - diffuse - characterized by reflux in the whole of the short saphenous vein, from the saphenopopliteal junction up to the medial malleolus.

Figure 2 -Reflux patterns in SSV.

Concerning reflux patterns, the most common among the short saphenous veins under study was type IV - segmental reflux (8.47%), followed by type III - distal reflux (4.6%), type II - proximal reflux (4.45%), type Vb - multisegmental reflux not affecting the saphenopopliteal junction (1.06%), type VI - diffuse reflux (0.99%), type Va - multisegmental reflux affecting the saphenopopliteal junction (0.28%) and type I - Giacomini vein (0.21%).

Sources of reflux

The most common source of reflux in short saphenous veins was superficial tributaries (70.24%), followed by saphenopopliteal junction (28.03%) and perforating veins (1.73%). Giacomini vein was found to be the cause of reflux in short saphenous vein in only 0.21% of cases (Table 3).

Table 3- Sources of reflux in short saphenous vein (SSV)

SSV - Sources of Reflux	n	%
Tributary	203	70.24
Perforating vein	5	1.73
Saphenopopliteal junction	81	28.03
Total	289	100

Sites of drainage

The most common site of drainage in short saphenous veins was the tributaries (in 83.33% of the limbs). Draining through perforating veins corresponded to 16.67% of the limbs (Table 4).

Table 4 - Sites of drainage in short saphenous vein (SSV)

SSV - Sites of drainage	n	%
Tributary	170	83.33
Perforating vein	34	16.67
Total	204	100

Saphenopopliteal junction

Concerning the position of the saphenopopliteal junction (assuming the popliteal fold as the reference point), it was observed that this junction was found to be at the level of popliteal fold in 54.6% of the limbs, and 4 cm above the popliteal fold in 12.85% of the limbs. The connection with the deep venous system was found to be: between 4 and 10 cm above the popliteal fold in 28.03% of the limbs; over 10 cm above the popliteal fold in 3.32% of the limbs; and under the popliteal fold in 0.07% of the limbs. The short saphenous vein was found to be connected to the great saphenous vein at proximal leg or thigh level in 1.13% of the limbs.

Table 5 - Position of the saphenopopliteal junction

Saphenopopliteal junction	n	%
In popliteal fold	773	54.6
Up to 4 cm above the popliteal fold	182	12.85
Between 4 and 10 cm above the popliteal fold	397	28.03
Over 10 cm above the popliteal fold	47	3.32
Connection with GSV in thigh or leg	16	1.13
Under popliteal fold	1	0.07
Total	1,416	100

DISCUSSION

Color Doppler ultrasound is the main complementary exam in the surgical planning for varicose vein surgery. An adequate planning leads to fewer chances of recurrence and provides more safety for the surgeon to perform the procedure. In this study, we are proposing a standardization of reflux patterns in saphenous veins, which may be used as a reference for medical practice and for scientific studies.

A prospective report by Hammarsten et al.³ evidenced that great saphenous vein saving surgery and standard stripping did not present different results in terms of recurrence and esthetic satisfaction of patients. However, it is necessary that the surgeon performs a functional anatomic study of the superficial venous system in order to choose the most suitable procedure (great saphenous vein saving surgery or standard stripping).³

Koyano & Sakagushi proposed a classification of reflux in saphenous veins based on continuous wave Doppler ultrasounds, with no direct evaluation of the vessels. Their classification presented five different reflux patterns in great saphenous veins (diffuse, from the groin to the proximal third of the leg, from the groin to thigh level, tributaries at the groin and tributaries of perforating veins) and four reflux patterns in the short saphenous veins (diffuse, from the saphenopopliteal junction to the distal third of the leg, in the proximal third of the leg). Since the authors used an indirect, non-invasive method for evaluating the vessels, their classification should be complemented.⁴ Still, they report that diffuse reflux pattern was most common both in great and short saphenous veins. However, we observed in our study that segmental reflux was predominant and diffuse reflux was one of the less frequent, both for great saphenous veins (9.9%) and for short saphenous veins (14.8%).

Myers et al. reported a study with 1,653 lower limbs with chronic venous insufficiency, and presented reflux patterns of the superficial venous system based on color Doppler ultrasounds. However, the exact location of the reflux was not established in the study; the authors presented only the incidences of reflux in the great and short saphenous systems and their correlation with reflux in the deep venous system. It was demonstrated that only 210 limbs (12%) did not present any reflux in the superficial venous system.⁵ In our study, absence of reflux was found to be 28% in great saphenous veins and 80% in short saphenous veins.

Luccas et al. presented their experience with the color Doppler ultrasound in evaluating reflux patterns in saphenous veins, at Universidade de Campinas (São Paulo State, Brazil). They identified the following patterns: type 0 - normal saphenous vein; type I - insufficiency in the whole of the saphenous trunk (13.6%); type II - insufficiency from the groin up to the knee (17%); type III - insufficiency from the groin up to the upper or medial third of the thigh (11.1%); type IV - insufficiency in the groin and collateral vessels (3.4%); and type V - segmental insufficiency, between the medial third of the thigh and the upper third of the leg (9.4%).⁶ Although the authors present a broader functional evaluation, some reflux patterns of great saphenous veins and especially anatomic variations in the mouth of short saphenous veins were not presented, which we consider to be crucial for preventing possible recurrences.⁷

A study conducted by Fisher et al. with 125 lower limbs in 77 patients who underwent a previous varicose vein surgery evidenced that color Doppler ultrasound showed reflux in the saphenofemoral junction in 60% of the limbs, whereas the clinical examination suggested reflux in 38% of the limbs (P < 0.001).⁸

Recurrent varicose veins were evaluated with color Doppler ultrasound by Labropoulos et al., who observed 29% of cases with reflux in saphenofemoral junction, both isolated or associated with segmental reflux in great saphenous vein. Most cases of recurrence in the great saphenous vein were due to incompetent perforating veins.^9,10

In the evaluation of short saphenous veins, it is important to highlight that the most frequent source of reflux observed was the superficial tributaries of the leg, and that the presence of saphenopopliteal junction in the popliteal fold was found to occur in more than 50% of the cases. If one is unaware of this information, it may lead to greater rates of recurrent varicose veins due to insufficient residual stumps.¹¹ Georgiev et al. established a correlation between the findings of Giacomini and recent studies with color Doppler ultrasound. In his anatomic studies, the vein in posterior thigh was present in 72% of the 51 limbs analyzed by Giacomini.¹² In their functional studies, Labropoulos et al. observed the presence of an incompetent Giacomini vein in 17.3% of 226 lower limbs with reflux in the superficial venous system.¹³

Furthermore, Perrin highlights the importance of studying the popliteal fold with reflux using color Doppler ultrasound, which allows to identify insufficiency in the short saphenous vein, in gastrocnemius vein and reflux in the popliteal axis, which cannot be identified at physical examination. The inclusion of such anatomic variations in the surgical planning allows for avoiding recurrences.¹³ De Maeseneer et al.¹⁴ evaluated 12 patients, who underwent classical ligation of the short saphenous vein due to recurrent varicose vein, with color Doppler ultrasound. Preoperative ultrasound revealed reflux in the high saphenopopliteal junction in 11 patients and reflux in Giacomini vein in one patient.

The authors of the present study conclude that, in order to conduct an adequate preoperative evaluation of patients with lower limb varicose veins, it is necessary to perform a functional anatomic study of the superficial venous system; there is a need for a standardization of the classifications for superficial venous insufficiency based on non-invasive diagnostic methods.

The classification presented here, as well as the results achieved with the evaluation of sites of reflux in great and short saphenous veins, evidenced the importance of these data in the planning for lower limb varicose vein surgery and in the final results, preventing possible recurrences or unnecessary stripping. Nevertheless, it is relevant to mention that preoperative vein mapping should be considered as an additional resource in the diagnosis and treatment planning, but not as the sole and definitive method to indicate surgery, which should actually be indicated after an analysis of the clinical situation of the patient.

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