PREVALENCE OF DEEP VENOUS REFLUX
AS PRIMARY AETIOLOGY
IN CASE OF
LOWER LIMB VARICOSE VEINS
ABSTRACT ID NO 99
INTRODUCTION
• Varicose veins
• Chronic venous insufficiency
• Venous reflux
AIM
• To study the prevalence of deep venous reflux
as primary aetiology in cases with lower limb
varicose veins.
• Isolated deep venous reflux.
OBJECTIVES
• The objectives will be to see the various
patterns and durations of below mentioned
refluxes in patients with lower limb varicose
veins.
– The Deep Venous Reflux
– The Sapheno-femoral & Sapheno-popliteal reflux
– The Perforator Reflux
MATERIALS & METHODS
• Sample size
– 110 cases of lower limb varicose veins that were
managed at this tertiary care centre during June 2012June 2014.
• Type of study
– A descriptive cross sectional study.
INCLUSION CRITERIA
• Clinically confirmed cases of varicose veins which
will be further classified on the basis of CEAP
classification.
• Cases of chronic venous insufficiency in the form of
skin changes, ulceration and lipodermatosclerosis.
• Patients who have not been treated earlier by
medical or surgical modality of treatment for
varicose veins.
EXCLUSION CRITERIA
• Patients with history of superficial and deep
vein thrombosis.
• Patients in the age group less than 15 yrs to
exclude the congenital causes of varicose
veins.
• Patients who have been treated earlier by
medical or surgical modality for varicose
veins.
DOPPLER EXAMINATION
• Patients were examined in
standing position.
• Axial scan and continuous scan
was performed for superficial
and deep venous system.
• The Valsalva maneuver was
used to elicit the presence of
reflux.
DEFINITION OF SIGNIFICANT REFLUX
• More than 500 msec
– Superficial veins.
– Deep femoral veins.
– Femoro-popliteal veins.
– Deep calf veins.
• More than 350 msec
– Perforators.
CASE 1
33 Y / Male
Varicose veins,
Ulcers, Skin changes
3 years duration
LLL
C2, 4, 6 Ep An Pr
CASE 1
CASE 2
46 Y / Female
Varicose veins,
Skin changes
2 years duration
LLL
C2, 4 Ep An Pr
CASE 2
CASE 3
50 Y / Female
Varicose veins, Skin
changes, Ulcer
7 years duration
RLL
C2, 4, 6 Ep An Pr
CASE 3
RESULTS
• The mean age of study population was 48.34 ± SD 12.9 years.
• CEAP distribution
 C4
 C5
 C6
-
67 (60.9 %)
05 ( 4.5 %)
11 (10.0 %)
• Superficial Incompetence
 SFJ
 SPJ
 Perforator
-
65 (59.1 %)
11 (10.0 %)
68 (61.8 %)
 Combined
 Isolated
-
42 (38.2 %)
08 ( 7.3 %)
• DVR
DEEP VENOUS REFLUX
Distribution of Segmental DVR
ISOLATED DVR
45
40
Number of patients
35
7%
30
25
Present
20
Absent
15
93%
10
5
0
Number of patients
PROX FV
DISTAL FV
POP V
GPJ
PTV
42
14
4
0
0
MEAN GSV DIAMETER
GSV diameter (mm)
SFJ reflux
Number of patients (n)
Present
p-value
65
Mean
SD
4.47
0.77
< 0.001
Absent
45
3.75
0.43
5
4
80
3
Sensitivity
GSV diameter
GSV
100
2
60
40
1
20
0
Mean GSV
diameter
Present
Absent
0
0
4.47
3.75
20
40
60
100-Specificity
80
100
DISTRIBUTION OF SFJ REFLUX & DVR
IN C4 - C6 GRADE
C4 - C6 Grade
SFJ Reflux
Present (n)
Percentage (%)
Present
44
67.69
Absent
21
32.31
Total
65
100.00
Deep Venous Reflux
C4 - C6 Grade
Present (n)
Percentage (%)
Present
31
73.81
Absent
11
26.19
Total
42
100.00
DISCUSSION
• Irodi et al.
– 12 % patients in C3 grade.
– 43% patients in C4 grade.
– 11 % patients in C5 grade.
– 34% patients in C6 grade.
• Mercer
– Study on 89 cases of lower limbs.
– Detected reflux at the SFJ in 59 legs (66 per cent) and
at the SPJ in 26 (29 per cent) by duplex imaging.
DISCUSSION
• Myers et al.
– Demonstrated combined prevalence of DVR and
reflux in superficial system to be 48 % in cases of
varicose veins.
• Hanrahan and associates
– Total incidence of deep system reflux to be 49.5%.
– Did not quantify the reflux to primary or
secondary.
DISCUSSION
• Irodi et al.
– Found 50 (50%) cases of deep venous reflux but none of
the cases had reflux in isolation.
• Myers et al. (1995)
– Found that out of 96 cases; 8% cases had isolated DVR.
• Hanrahan et al. (1991)
– Conducted a doppler study on 95 patients
– Found the prevalence of deep venous reflux to be 2%
DISCUSSION
• Joh & Park
– used recumbent patient position.
– The mean diameter of a GSV with reflux was 6.4 ± 2.0
mm.
– Normal GSV mean diameter measured 5.0 ± 2.4 mm.
– GSV diameter threshold of 5.05 mm and greater had
the best value for predicting reflux.
– The sensitivity and specificity at 5.05 mm were 76% and
60%, respectively.
LIMITATIONS OF STUDY
• No control groups of normal cases were taken
• Although quantitative assessment of deep venous reflux
has been done, insignificant reflux in GPJ and PTV could
have been due to inadequate valsalva technique.
• Non - availability of pneumatic cuff inflation technique in
our study would have contributed to the results.
• Study of GSV and SSV has been primarily done at the
junctional sites. Assessment of segmental reflux in these
territories away from the junctional site would have given
better correlation between various factors.
REFERENCES
•
Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Ashraf Mansour M et al. Definition of venous reflux in lower extremity veins. J Vasc Surg. 2003;
38(4): 793–798.
•
Labropoulos N, Tassiopoulos AK, Kang SS, Mansour MA, Littooy FN, Baker WH. Prevalence of deep venous reflux in patients with primary superfricial vein
incompetence. J Vasc Surg. 2000; 32:663-8.
•
Myers KA, Ziegenbein RW, Zeng GH, Matthews PG. Duplex ultrasonography scanning for chronic venous disease: patterns of venous reflux. J Vasc Surg. 1995;
21:605-12.
•
Bergan JJ. The Vein Book. London: Elsevier; 2007.
•
Irodi A, Shyamkumar, Keshava N, Agarwal S, Korah IP, Sadhu D. Ultrasound Doppler Evaluation of the Pattern of Involvement of Varicose Veins in Indian Patients.
Indian J Surg. 2011. 73(2):125–130.
•
Joh JH, Park HC. The cutoff value of saphenous vein diameter to predict reflux. J Korean Surg Soc. 2013; 85:169-174.
•
Hanrahan LM, Araki CT, Fisher JB, et al. Evaluation of the perforating veins of the lower extremity using high resolution duplex imaging. J Cardiovasc Surg. 1991;
32:87-97.
•
Mercer MG, Scott DJA, Berridge DC: Preoperative duplex imaging is required before all operations for primary varicose veins. British Journal of Surgery. 1998; 85:
1495-1497.
•
Lees TA, Lambert D. Patterns of venous reflux in limbs with changes associated with chronic venous insufficiency. Br J Surg. 1993; 80:725-28.
•
Masuda EM, Kistner RL, Eklof B. Prospective study of duplex scanning for venous reflux: comparison of Valsalva and pneumatic cuff techniques in the reverse
Trendelenburg and standing positions. J Vasc Surg. 1994; 20:711-720.
•
Welch HJ, Young CM, Semegran AB. Duplex assessment of venous reflux and chronic venous insufficiency: the significance of deep venous reflux. J Vasc Surg.
1996; 24: 755–762.
•
Jeanneret C, Labs KH. Physiological reflux and venous diameter change in the proximal lower limb veins during a standardised Valsalva maneuver. Eur J Vasc
Endovasc Surg. 1999; 17(5):398–403.
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