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Color-flow duplex scanning in the assessment of recurrent varicose veins *
(Portuguese PDF version)

Graciliano José França,¹ Jorge Rufino Ribas Timi², Enrique Antônio Vidal³, Aguinaldo de Oliveira⁴, Fábio Secchi⁵, Marcio Miyamotto⁶

1. MSc. Vascular ultrasonographer, Clínica Ecodoppler Colorido and Hospital das Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil.
2. Ph.D. Adjunct professor, Vascular Surgery, UFPR. Vascular surgeon, Vascular Surgery Service Prof. Dr. Elias Abrão, Curitiba, PR, Brazil.
3. Vascular ultrasonographer, Clínica Ecodoppler Colorido, Curitiba, PR, Brazil.
4. Master. Vascular ultrasonographer, Clínica Ecodoppler Colorido, Curitiba, PR, Brazil.
5. Master. Vascular surgeon.
6. Vascular and endovascular surgeon, Vascular Surgery Service Prof. Dr. Elias Abrão, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, PR, Brazil.

* Study performed at Clínica Ecodoppler Colorido, Curitiba, PR, Brazil.

Correspondence:
Graciliano José França
Rua Bruno Filgueira, 2054/702
CEP 80730-380 - Curitiba, PR, Brazil
Phone: +55 41 335.5568
E-mail: gracilianojf@terra.com.br

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ABSTRACT

Objective: The aim of the present study is to use color-flow duplex scanning to determine the prevalence of reflex in the greater saphenous vein stump in patients with recurrent varicose veins after saphenous vein stripping. All other possible causes of recurrence were also evaluated.

Methods: Over a 3-year period, 469 patients with recurrent varicose veins were prospectively assessed. The cohort had 45 men and 424 women, with a mean age of 53.5 years, ranging from 25 to 82 years. Altogether, 683 lower limbs were assessed. In each limb, all sites of reflux in the superficial, deep and perforator systems that could account for varicose vein recurrence were evaluated.

Results: Reflux in the greater saphenous vein stump was identified in 188 out of the 683 limbs (27.54%) of the cases. In the majority of the cases (24.75%), reflux in the greater saphenous vein stump was associated with other causes of recurrence, such as residual greater saphenous vein in the thigh (4.68%); residual greater saphenous vein in the leg (8.78%); short saphenous vein (33.52%); deep venous system (14.2%); thigh perforators (26.35%); leg perforators (61.05%); lateral accessory saphenous vein (7.32%); medial accessory saphenous vein (2.78%). In most cases, recurrence was caused by one (33.39%) or two (40.4%) sites of reflux.

Conclusion: The present study allows the following conclusions: the prevalence of reflux in the greater saphenous vein stump is 27.54%; in most cases, reflux in the greater saphenous vein stump is associated with other causes of recurrence.

Key-words: saphenous vein, varicose vein, duplex scanning.

J Vasc Br 2005;4(2):161-6

Varicose veins in the lower limbs are a common problem that can affect up to 50% of the adult population.¹ The surgical treatment of the varicose veins does not completely avoid the development of new varices and, consequently, recurrence is frequent. Recurrence rate can reach 50% 5 years after the surgery.^2-5 Around 20% of surgeries of varicose veins in the lower limbs are due to recurrent varicose veins.⁶

The clinical definition for recurrent varicose veins is the development of new varices of the lower limbs after a primary eradication.⁵ In the past, the inappropriate ligation of the great saphenous vein at the aortic arch was the most frequent cause of recurrence.⁷ This situation remains up to the present time, despite the significant progress in the preoperative treatment and assessment of varicose veins in the lower limbs.⁸

The most important phase for a correct planning of the surgery of recurrent varicose veins is to establish its main cause.⁹ Historically, intraoperative findings during reoperation and the preoperative phlebography were used to locate the sites of venous insufficiency possibly related to the recurrence.^7,10

More recently, the color-flow duplex scanning has been used to identify the site of valvular incompetency.¹¹ The assessment of the aortic arch of the great saphenous vein by the color-flow duplex scanning can provide anatomical and hemodynamic information, which are important for patients previously submitted to saphenous vein stripping, once the reflux in the residual stump is one of the most frequent causes of recurrence.^8,12,13 Moreover, the color-flow duplex scanning can identify other sources of reflux related to the recurrence. It is currently the main examination for assessing this type of patient.^2,4,8

The aim of this study was to use color-flow duplex scanning to assess the prevalence of reflux in the great saphenous vein stump in patients with recurrent varicose veins after saphenous vein stripping, separately or associated to other causes of recurrence.

PATIENTS AND METHODS

From July 1997 to June 2000, 824 limbs of 589 patients with recurrent varicose veins were prospectively assessed by the color-flow duplex scanning. We excluded from the study 141 limbs of 120 patients who presented recurrent varicose veins without previous total great saphenous vein stripping and cases in which only the saphenous vein stripping was performed in the leg, not including the sapheno-femoral junction. Therefore, 683 limbs of 469 patients were included in this study. Most patients were female (45 men and 424 women), with mean age of 53.5 years, ranging from 25 to 82 years.

The study was approved by the research ethics committee of the Hospital de Clínicas of Universidade Federal do Paraná.

The examinations were performed with the use of a System Five, General Electric Diasonics Ultrasound, using a 5-10-MHz linear transducer.

The technique used for all examinations had been used in other studies in which the reflux research was essential.², ^14,15 The patient was examined in the 30-degree reverse Trendelenburg position. The knee was slightly flexed and laterally rotated, as described by other authors.¹⁶

During the examination, the following segments were analyzed: in the deep venous system: posterior and fibular femoral, popliteal and tibial veins; in the superficial system: short saphenous vein, great saphenous vein (when present), medial and lateral accessory saphenous veins, besides the perforating veins.

There was no technical difficulty to visualize the great saphenous vein stump due to tissue fibrosis caused by previous surgery.

All segments were assessed by transversal and longitudinal imaging and tested as to compressibility to exclude venous thrombosis. The spectral analysis in each assessed segment was obtained during normal breathing, Valsalva maneuver, and distal manual compression.¹⁷ Main reflux sites can be seen in Table 1 (Figure 1).

Table 1 - Main sites of reflux assessed in recurrent varicose veins after saphenous vein stripping

Sites of reflux

Great saphenous vein stump

Residual great saphenous vein in the thigh

Residual great saphenous vein in the leg

Short saphenous vein

Deep venous system

Perforating veins in the thigh

Perforating veins in the leg

Lateral accessory saphenous vein

Medial accessory saphenous vein

 

Figure 1 - a) sapheno-femoral junction, b) residual great saphenous vein, c) short saphenous vein, d) insufficient perforating vein.

Reflux was considered when the reverse flow lasted for more than 1 second with the Valsalva maneuver and manual distal compression-decompression. Reflux was longitudinally observed with color-flow and spectral analysis. The examinations were performed by three vascular ultrasonographers involved in the study.

RESULT

The presence of reflux in the great saphenous vein stump as an isolated cause of recurrent varicose veins after saphenous vein stripping occurred in 19 assessed limbs (2.79%). Reflux in the great saphenous vein stump was more frequent associated with other causes of recurrence, being present in 169 (24.75%) assessed limbs. Therefore, in 188 out of 683 assessed limbs, there was a great saphenous vein stump with reflux, causing a recurrent varicose vein, which corresponds to 27.54% of cases (Table 2).

Table 2 - Prevalence of great saphenous vein stump as an isolated or associated factor in the recurrent varicose veins

Cause of recurrence	Number of limbs	%
Isolated great saphenous vein stump	19	2.79
Associated great saphenous vein stump	169	24.75
Other causes	460	67.34
Recurrence with no site of reflux	35	5.12
Total	683	100.00

 

However, in most limbs, other causes of recurrence were identified, besides the great saphenous vein stump, such as the reflux in the residual great saphenous vein in the thigh or leg, in the short saphenous vein, in the perforating veins of the thigh or leg, and in the accessory saphenous veins (Table 3).

Table 3 - Other causes of recurrent varicose veins

Sites of reflux	Number of limbs	%
Residual great saphenous vein in the thigh	32	4.68
Residual great saphenous vein in the leg	60	8.78
Short saphenous vein	229	33.52
Deep venous system	97	14.2
Perforating veins in the thigh	180	26.35
Perforating veins in the leg	417	61.05
Lateral accessory saphenous vein	50	7.32
Medial accessory saphenous vein	19	2.78

 

In most assessed limbs, there was one or two sites of reflux. In 35 assessed limbs, recurrent varicose veins were not related to any of these sites of reflux (Table 4).

Table 4 - Number of sites of reflux in each limb

Sites of reflux (n)	Number of limbs	%
0 (no site of reflux)	35	5.12
1	228	33.39
2	276	40.4
3	94	13.77
4	40	5.85
5	10	1.47
Total	683	100.00

 

DISCUSSION

The surgical treatment of varicose veins in the lower limbs is associated with recurrence rates that can vary from 7 to 65%,^18,19 indicating a gradually progressive disease and the need of an adequate treatment plan.

The precise anatomical assessment of the sites of reflux in the preoperative period is essential for a correct surgical approach, reducing the probability of future recurrences. As in the primary assessment, the color-flow duplex scanning is considered by several authors as the choice examination in the assessment of the venous reflux in recurrent varicose veins.^{2-5,8,12-14,20-25}

In this study, the color-flow duplex scanning was performed in all patients by three experienced vascular ultrasonographers. This fact is very important for the study credibility, since the duplex scanning is often criticized for being a method dependent on the ultrasonographer.²⁶

It is also important to have access to a high quality device. In the present study, the examinations were performed in a single device, followed by a specific sequence in the assessment of every possible site of reflux in the superficial and deep system and in the perforating veins, independently from the physician who performed the examination.

Controversies arise on different techniques to perform the examination. Some authors perform the examination with the patient standing erect, because the reflux physiologically occurs in this position, caused by gravity.^27-29 Patients in this study were submitted to the examinations in a 30-degree reverse Trendelenburg position, as adopted by other authors.^16,25 Besides being more comfortable for the patient, since it lasts a considerable amount of time (50 to 60 minutes when bilateral), there is no significant difference in relation to the patient's positioning in the assessment of the venous reflux.^14,15 Moreover, it seems to us that a determining factor is the examiner's experience. The best position would be the one that he is most used to and that can produce better results. The same thinking can be applied to the reflux assessment using distal compression to the transducer, manually or through pneumatic cuffs. Authors use the manual distal compression for being more simple, once there is no significant difference between both assessment techniques in the presence of venous reflux.²⁹

The main focus of the study was to analyze the reflux in the great saphenous vein stump in patients with recurrent varicose veins after saphenous vein stripping, considered by several authors as the main factor related to the recurrent varicose vein.^{2,12,21,30,31} This sample had a prevalence of 27.54% (188/683), similar to what has been reported in other publications.^4,17 In some other clinical studies, however, the reflux in the saphenous vein stump is related to recurrent varicose veins in more than 50% of cases.^21,23,31 Such discrepancy in prevalence may be related to previous surgical treatment. The routine use of the great saphenous vein stripping, when necessary, reduces the recurrence rates when compared to the surgery with preservation of the saphenous vein, in which only the ligation at the sapheno-femoral junction is performed.^25,32 Other authors report low recurrence rates, even in the surgery with preservation of the saphenous vein, when phlebography is routinely used to locate and properly treat the thigh perforating veins.³³

The reflux in the great saphenous vein stump as an isolated factor was responsible for the recurrent varicose veins in only 3% of cases. In 24% of assessed limbs, the reflux in the stump was associated with reflux in other sites, as demonstrated in another study.⁴

Although the great saphenous vein stripping has been performed in all patients, in some cases it was not performed in all its extension. Valvular reflux in the residual great saphenous vein in the thigh was found in 4.68% of assessed limbs. This type of reflux usually occurs in association with the presence of an insufficient perforating vein in the thigh.^4,22 In cases in which the great saphenous vein stripping of the aortic arch was performed up to the knee level, we found signs of residual saphenous vein insufficiency in the leg in 8.78% of cases. In spite of avoiding a possible saphenous nerve lesion in the leg, which is closely related to the saphenous vein in this region, the preservation of this segment of the great saphenous vein below the knee may be related to the recurrent varicose veins.³⁴ Other sources of valvular reflux in the superficial venous system were observed in the short saphenous vein in 33.52%, and in accessory saphenous veins in 10.10% of cases, as described by other authors.^14,35,36

The valvular reflux in the perforating vein system was the most common finding in the assessed limbs. In 61.05% of cases, there were insufficient perforating veins in the leg, and 26.35% presented insufficient perforating veins in the thigh. Although related to other sources of venous reflux in most cases, the presence of incompetent perforating veins plays a major role in the recurrent varicose veins.^13,14,23,37

In our study, the reflux in the deep venous system was observed in 14.2% of limbs with recurrent varicose veins, similar to the occurrence described in the literature.^38,39 Approximately 11% of cases of reflux in the deep system were considered primary and 3% secondary to the previous venous thrombosis with complete recanalization. Therefore, the contribution of the deep reflux in this group of assessed patients is small, once the reflux is more frequently originated in superficial veins, as it was observed in another study.⁴⁰

In the 683 assessed lower limbs, the recurrent varicose veins were related to, in most cases, one or two sites of reflux. In a few cases, around 5% of assessed limbs, any sites of incompetence were detected, a proportion which is similar in the literature.^41,42 In these patients, the recurrence occurred only in isolated superficial varicose veins.

CONCLUSION

The present study leads to the conclusion that, in this sample, the prevalence of reflux in the great saphenous vein stump in patients with recurrent varicose veins after saphenous vein stripping was 27.54%. In most cases, the reflux in the great saphenous vein stump is associated with other causes of recurrence.

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